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General NPI Number Information
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NPI Number | 1992597496
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Entity Type | Individual
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Provider Name | JACQUELINE BENNETT C.E.O
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Gender | Female
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Dates
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Enumeration Date | 05/20/2025
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Last Update Date | 05/20/2025
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Provider Practice Location Address
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Address Line | 1139 HWY 54 E LANIER AVE SUITE J
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City | FAYETTEVILLE
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State | GA
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Zip | 30215
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Country | US
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Telephone | 470-302-7769
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Fax | 888-666-1770
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Provider Business Mailing Address
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Address Line | 1545 N EXPRESSWAY UNIT 137
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City | GRIFFIN
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State | GA
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Zip | 30223-1746
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Country | US
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Telephone | 404-934-2936
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Fax | 888-666-1770
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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 | 246RM2200X
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Taxonomy Name | Medical Laboratory Technician
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License Number | 9435480646JB
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License Number State | GA
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