Provider Demographics
NPI:1932653532
Name:THELEMAQUE, JEAN JR
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:THELEMAQUE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 HOLMES ST NW
Mailing Address - Street 2:#H
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-7684
Mailing Address - Country:US
Mailing Address - Phone:347-595-5453
Mailing Address - Fax:
Practice Address - Street 1:3648 CHAMBLEE TUCKER RD
Practice Address - Street 2:#F
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4403
Practice Address - Country:US
Practice Address - Phone:770-493-7750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility