Provider Demographics
NPI:1548775448
Name:BRANNON, JEAN (LAC)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:BRANNON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 MOSLEY RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-2606
Mailing Address - Country:US
Mailing Address - Phone:706-338-6843
Mailing Address - Fax:
Practice Address - Street 1:1050 E PIEDMONT RD STE 150
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-0903
Practice Address - Country:US
Practice Address - Phone:770-450-8686
Practice Address - Fax:770-450-8686
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000291171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty