Provider Demographics
NPI:1427561703
Name:BAUTISTA, JENNY K (MS)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:K
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:K
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:729 WYNHOLLOW TRCE APT 3
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-4015
Mailing Address - Country:US
Mailing Address - Phone:347-575-0445
Mailing Address - Fax:
Practice Address - Street 1:270 CARPENTER DR STE 400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4933
Practice Address - Country:US
Practice Address - Phone:678-460-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health