Provider Demographics
NPI:1467636696
Name:JEANNE D. WYATT, M.S.W., L.C.S.W., P.C.
Entity Type:Organization
Organization Name:JEANNE D. WYATT, M.S.W., L.C.S.W., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:770-449-4581
Mailing Address - Street 1:5672 PEACHTREE PARKWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2847
Mailing Address - Country:US
Mailing Address - Phone:770-449-4581
Mailing Address - Fax:770-449-4123
Practice Address - Street 1:5672 PEACHTREE PARKWAY,
Practice Address - Street 2:SUITE B
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2847
Practice Address - Country:US
Practice Address - Phone:770-449-4581
Practice Address - Fax:770-449-4123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001696101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBGCTMedicare PIN