MEDICARE: PLM METTA HEALING OASIS, LLC

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	103TF0200X	Forensic Psychologist	PSY 003657	GA
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	PSY 003657	GA
3	103TB0200X	Cognitive & Behavioral Psychologist	PSY 003657	GA
4	103TC0700X	Clinical Psychologist	PSY 003657	GA

General Provider Information

NPI Number	:	1316385446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLM METTA HEALING OASIS, LLC

Provider Business Mailing Address
First Line	:	920 DANNON VW SW STE 3203
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-2161
Country	:	US
Telephone Number	:	404-590-8156
Fax Number	:	206-350-3122

Provider Business Practice Location Address
First Line	:	920 DANNON VW SW STE 3203
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-2161
Country	:	US
Telephone Number	:	404-590-8156
Fax Number	:	206-350-3122

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	PAMELA L. JENKINS
Credential	:	PHD
Telephone Number	:	404-590-8156

Provider Enumeration Date	:	06/11/2013
Last Update Date	:	02/24/2021

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