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? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 049473917 | Other | DRIVERS LICENSE |