MEDICARE: SOLDIER THERAPIST

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1780348458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLDIER THERAPIST

Provider Business Mailing Address
First Line	:	1760 LAKES PKWY UNIT 4416
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-6194
Country	:	US
Telephone Number	:	678-805-7181
Fax Number	:

Provider Business Practice Location Address
First Line	:	1760 LAKES PKWY UNIT 4416
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-6194
Country	:	US
Telephone Number	:	678-805-7181
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RAYMOND EDWIN JEANES
Credential	:	LCSW
Telephone Number	:	678-805-7181

Provider Enumeration Date	:	10/28/2021
Last Update Date	:	02/28/2022

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