=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922693654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JABALI WELLNESS GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2021
-----------------------------------------------------
Last Update Date | 03/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8305H OFFICE PARK DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-6935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-203-0080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8305H OFFICE PARK DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-6935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-203-0080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIOR CLINICIAN
-----------------------------------------------------
Name | DR. FELITA BUSH
-----------------------------------------------------
Credential | D.PC
-----------------------------------------------------
Telephone | 470-203-0080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------