Provider Demographics
NPI:1275653172
Name:OTWELL, JASON ROBERT
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ROBERT
Last Name:OTWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6111 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:BUILDING C
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-6049
Mailing Address - Country:US
Mailing Address - Phone:770-396-0232
Mailing Address - Fax:770-399-0007
Practice Address - Street 1:6111 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:BUILDING C
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6049
Practice Address - Country:US
Practice Address - Phone:770-396-0232
Practice Address - Fax:770-399-0007
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003612101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional