Provider Demographics
NPI:1184845513
Name:OWENS, JACQUELYN DENISE (APRN, CNS/PMH-BC)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELYN
Middle Name:DENISE
Last Name:OWENS
Suffix:
Gender:F
Credentials:APRN, CNS/PMH-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3263 BOULDER BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3004
Mailing Address - Country:US
Mailing Address - Phone:770-482-7184
Mailing Address - Fax:
Practice Address - Street 1:3188 ATLANTA RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8256
Practice Address - Country:US
Practice Address - Phone:770-319-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN115796163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA013206300Medicare UPIN