MEDICARE: DR. JO D FADDIS DMIN

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	106H00000X	Marriage & Family Therapist	000295	GA

General Provider Information

NPI Number	:	1346333200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JO D FADDIS DMIN

Provider Business Mailing Address
First Line	:	2310 BRIARCLIFF RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2802
Country	:	US
Telephone Number	:	404-325-0738
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 BRIARCLIFF RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2802
Country	:	US
Telephone Number	:	404-325-0738
Fax Number	:

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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