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NPI Code Detail

MEDICARE: JASON ROBERT OTWELL

MEDICARE: JASON ROBERT OTWELL
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
1101YP2500XProfessional CounselorLPC003612GA

General Provider Information

NPI Number : 1275653172
Entity Type Code : Individual
Provider Name (Legal Business Name) : JASON ROBERT OTWELL
Provider Business Mailing Address
First Line : 6111 PEACHTREE DUNWOODY RD NE
Second Line : BUILDING C
City : ATLANTA
State : GA
Zip : 30328-6049
Country : US
Telephone Number : 770-396-0232
Fax Number : 770-399-0007
Provider Business Practice Location Address
First Line : 6111 PEACHTREE DUNWOODY RD NE
Second Line : BUILDING C
City : ATLANTA
State : GA
Zip : 30328-6049
Country : US
Telephone Number : 770-396-0232
Fax Number : 770-399-0007
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/02/2007
Last Update Date : 07/08/2007

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Directions to “ JASON ROBERT OTWELL ” Practice Location

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