Provider Demographics
NPI:1891447967
Name:JEMISON, LETITIA N
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:N
Last Name:JEMISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LETITIA
Other - Middle Name:N
Other - Last Name:JEMISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CERTIFIED LIFE COACH
Mailing Address - Street 1:4101 STRATFORD CIR
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-8120
Mailing Address - Country:US
Mailing Address - Phone:267-699-8212
Mailing Address - Fax:
Practice Address - Street 1:4101 STRATFORD CIR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-8120
Practice Address - Country:US
Practice Address - Phone:267-699-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000-00-0000Medicaid