Provider Demographics
NPI:1063846509
Name:POULOS, JENNIFER LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:POULOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 N HIGHLAND AVE NE
Mailing Address - Street 2:B10
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3400
Mailing Address - Country:US
Mailing Address - Phone:770-656-1365
Mailing Address - Fax:
Practice Address - Street 1:340 BOULEVARD NE
Practice Address - Street 2:SUITE 345
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1273
Practice Address - Country:US
Practice Address - Phone:404-653-0322
Practice Address - Fax:404-653-0466
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-01
Last Update Date:2013-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003708103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent