MEDICARE: MS. JALISA CONKLIN LMSW

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	101Y00000X	Counselor	MSW012251	GA

General Provider Information

NPI Number	:	1780470369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JALISA CONKLIN LMSW

Provider Business Mailing Address
First Line	:	445 WINN WAY
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1707
Country	:	US
Telephone Number	:	404-294-3836
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 CLIFTON SPRINGS RD
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30034-4606
Country	:	US
Telephone Number	:	404-892-4646
Fax Number	:

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

Provider Enumeration Date	:	04/18/2025
Last Update Date	:	04/18/2025

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