Provider Demographics
NPI:1669053104
Name:BUCHANAN, JERELYN
Entity type:Individual
Prefix:
First Name:JERELYN
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 ARROWHEAD BLVD APT 62D
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1159
Mailing Address - Country:US
Mailing Address - Phone:404-952-4103
Mailing Address - Fax:
Practice Address - Street 1:330 ARROWHEAD BLVD APT 62D
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1159
Practice Address - Country:US
Practice Address - Phone:404-952-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-162485106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician