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General NPI Number Information
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NPI Number | 1699101147
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Entity Type | Organization
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Legal Business Name | JIMMY'S MAGNOLIA TREE INC
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Dates
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Enumeration Date | 09/16/2013
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Last Update Date | 09/16/2013
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Provider Practice Location Address
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Address Line | 1526 WESTWOOD AVE SW
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City | ATLANTA
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State | GA
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Zip | 30310-2316
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Country | US
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Telephone | 404-748-9276
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Fax | 404-941-7929
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Provider Business Mailing Address
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Address Line | 1526 WESTWOOD AVE SW
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City | ATLANTA
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State | GA
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Zip | 30310-2316
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Country | US
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Telephone | 404-748-9276
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. JAN N TROTTER
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Credential |
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Telephone | 404-748-9276
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | CLA001050
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License Number State | GA
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