Provider Demographics
NPI:1477684025
Name:JEWETT, MINDY B (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:B
Last Name:JEWETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 LONGVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1512
Mailing Address - Country:US
Mailing Address - Phone:678-333-6311
Mailing Address - Fax:
Practice Address - Street 1:465 WINN WAY
Practice Address - Street 2:SUITE 221
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1753
Practice Address - Country:US
Practice Address - Phone:404-292-3810
Practice Address - Fax:404-292-3848
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0030451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBFQTMedicare ID - Type Unspecified
GAP96859Medicare UPIN