=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619006921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDY JACOBSON MD PC M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2007
-----------------------------------------------------
Last Update Date | 07/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1485 LAVISTA RD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30324-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-325-5677
-----------------------------------------------------
Fax | 404-325-9029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1485 LAVISTA RD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30324-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-325-5677
-----------------------------------------------------
Fax | 404-325-9029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 038811
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------