MEDICARE: JIMMY'S MAGNOLIA TREE INC

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	251C00000X	Developmentally Disabled Services Day Training Agency	CLA001050	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	972175212A	OTHER	GA	COMP WAVIER

General Provider Information

NPI Number	:	1699101147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIMMY'S MAGNOLIA TREE INC

Provider Business Mailing Address
First Line	:	1526 WESTWOOD AVE SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-2316
Country	:	US
Telephone Number	:	404-748-9276
Fax Number	:

Provider Business Practice Location Address
First Line	:	1526 WESTWOOD AVE SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-2316
Country	:	US
Telephone Number	:	404-748-9276
Fax Number	:	404-941-7929

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. JAN N TROTTER
Credential	:
Telephone Number	:	404-748-9276

Provider Enumeration Date	:	09/16/2013
Last Update Date	:	09/16/2013

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