Provider Demographics
NPI:1811517915
Name:WASHINGTON, JESSICA ELAINE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:WASHINGTON
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 1:1135 SENOIA RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1625
Mailing Address - Country:US
Mailing Address - Phone:770-626-3044
Mailing Address - Fax:
Practice Address - Street 1:1135 SENOIA RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1625
Practice Address - Country:US
Practice Address - Phone:770-626-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-21-53368103K00000X
GARBT-19-85072106S00000X
GA1-21-53168103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003218736AMedicaid