Provider Demographics
NPI:1558874974
Name:JENESIS CONSULTING AND DEVELOPMENT
Entity Type:Organization
Organization Name:JENESIS CONSULTING AND DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-464-8223
Mailing Address - Street 1:4274 BELAIR FRONTAGE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4274 BELAIR FRONTAGE RD STE 1
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9428
Practice Address - Country:US
Practice Address - Phone:678-464-8223
Practice Address - Fax:706-432-6290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA049473917OtherDRIVERS LICENSE