MEDICARE: JAZELLE WILSON

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	104100000X	Social Worker	MSW010930	GA

General Provider Information

NPI Number	:	1568865905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAZELLE WILSON

Provider Business Mailing Address
First Line	:	285 W WIEUCA RD NE # 4357
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-3321
Country	:	US
Telephone Number	:	470-387-9044
Fax Number	:

Provider Business Practice Location Address
First Line	:	285 W WIEUCA RD NE # 4357
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-3321
Country	:	US
Telephone Number	:	470-387-9044
Fax Number	:

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

Provider Enumeration Date	:	09/30/2014
Last Update Date	:	12/13/2025

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