Provider Demographics
NPI:1639375280
Name:DAVIDOW, JAYNE LEWIS (PT)
Entity Type:Individual
Prefix:MS
First Name:JAYNE
Middle Name:LEWIS
Last Name:DAVIDOW
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 1:1335 LAKE CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2849
Mailing Address - Country:US
Mailing Address - Phone:770-587-0516
Mailing Address - Fax:770-587-0516
Practice Address - Street 1:1335 LAKE CHARLES DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2849
Practice Address - Country:US
Practice Address - Phone:770-587-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT000990171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor