Provider Demographics
NPI:1922792258
Name:LAWRENCE, JALEN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:JALEN
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 PARKLAKE DR NE APT 1325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2882
Mailing Address - Country:US
Mailing Address - Phone:478-973-5259
Mailing Address - Fax:
Practice Address - Street 1:3161 HOWELL MILL RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2135
Practice Address - Country:US
Practice Address - Phone:404-351-5812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013620225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist