Provider Demographics
NPI:1669623799
Name:WEIDNER, J.D. (PHD)
Entity type:Individual
Prefix:
First Name:J.D.
Middle Name:
Last Name:WEIDNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 HERITAGE MANOR WALK
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1002
Mailing Address - Country:US
Mailing Address - Phone:404-317-9566
Mailing Address - Fax:
Practice Address - Street 1:2750 HERITAGE MANOR WALK
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034
Practice Address - Country:US
Practice Address - Phone:404-317-9566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL-MH21136101YM0800X
GAGA-LPC009051101YM0800X
101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC009051OtherSTATE LICENSE
FLMH21136OtherSTATE LICENSE