Provider Demographics
NPI:1144788142
Name:JAYTYN LLC
Entity Type:Organization
Organization Name:JAYTYN LLC
Other - Org Name:JAYTYN LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JOHNY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:256-457-3071
Mailing Address - Street 1:4310 BRONTE LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4981
Mailing Address - Country:US
Mailing Address - Phone:256-457-3071
Mailing Address - Fax:
Practice Address - Street 1:4600 BROSWELL ROAD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:256-457-3071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-08
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67277OtherINTERNAL MEDICINE