MEDICARE: JACQUELINE IRWIN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW000334	GA

General Provider Information

NPI Number	:	1053413963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE IRWIN LCSW

Provider Business Mailing Address
First Line	:	2281 BRIANWOOD TRL
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-1719
Country	:	US
Telephone Number	:	404-667-7267
Fax Number	:

Provider Business Practice Location Address
First Line	:	1493 LAVISTA RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-3846
Country	:	US
Telephone Number	:	404-667-7267
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	08/13/2010

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