Provider Demographics
NPI:1750906749
Name:TOLBERT, JENNIFER
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:TOLBERT
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:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7912
Mailing Address - Country:US
Mailing Address - Phone:404-583-5043
Mailing Address - Fax:
Practice Address - Street 1:123 DACULA ROAD
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7912
Practice Address - Country:US
Practice Address - Phone:404-583-5043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-19-76965106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARBT-19-76965OtherBEHAVIOR TECHNICIAN
GA1750906749Medicaid