Provider Demographics
NPI:1366775892
Name:WASHINGTON, JACQUELINE YVETTE
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:YVETTE
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 LAUGHLIN DR
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-6015
Mailing Address - Country:US
Mailing Address - Phone:770-833-2851
Mailing Address - Fax:888-493-4555
Practice Address - Street 1:116 LAUGHLIN DR
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-6015
Practice Address - Country:US
Practice Address - Phone:770-833-2851
Practice Address - Fax:770-957-0522
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA737485550BMedicaid