Provider Demographics
NPI:1528386141
Name:HENRY, JACQUELYN MARIE (PT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:MARIE
Last Name:HENRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5361 BROWNWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-4719
Mailing Address - Country:US
Mailing Address - Phone:404-849-2710
Mailing Address - Fax:
Practice Address - Street 1:5361 BROWNWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-4719
Practice Address - Country:US
Practice Address - Phone:404-849-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA199540486AMedicaid