Provider Demographics
NPI:1376905117
Name:JACOWAY, ATHENA
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:JACOWAY
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 1:1631 BRENTWOOD XING SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6300
Mailing Address - Country:US
Mailing Address - Phone:678-754-3507
Mailing Address - Fax:
Practice Address - Street 1:2258 NORTHLAKE PKWY
Practice Address - Street 2:390
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4019
Practice Address - Country:US
Practice Address - Phone:678-754-3507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO0781391744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management