Provider Demographics
NPI:1457670663
Name:MARCUS AUTISM CENTER
Entity Type:Organization
Organization Name:MARCUS AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JAQUESS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-785-9443
Mailing Address - Street 1:1920 BRIARCLIFF RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4010
Mailing Address - Country:US
Mailing Address - Phone:404-785-9400
Mailing Address - Fax:
Practice Address - Street 1:1920 BRIARCLIFF RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4010
Practice Address - Country:US
Practice Address - Phone:404-785-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HEALTHCARE OF ATLANTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003405133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty