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General NPI Number Information
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NPI Number | 1689609547
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Entity Type | Individual
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Provider Name | JAY W JOHANSEN MD, PHD
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Gender | Female
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Dates
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Enumeration Date | 07/11/2006
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Last Update Date | 09/17/2013
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Provider Practice Location Address
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Address Line | 1364 CLIFTON RD NE
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City | ATLANTA
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State | GA
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Zip | 30322-1059
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Country | US
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Telephone | 404-778-5762
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Fax |
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Provider Business Mailing Address
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Address Line | 1610 QUEENSLAND CT
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City | ALPHARETTA
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State | GA
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Zip | 30005-6970
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Country | US
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Telephone | 404-273-5564
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 036188
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License Number State | GA
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