Provider Demographics
NPI:1255697280
Name:SAMPLE, JANA (LAC)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2563 DRESDEN DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 E PACES FERRY RD NE
Practice Address - Street 2:SUITE 201
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3313
Practice Address - Country:US
Practice Address - Phone:404-528-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA350171100000X
CAAC 16064171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist