Basic Information
| Provider Information | |||||||||
| NPI: | 1477684025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEWETT | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2060 LONGVIEW WAY | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783336311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 465 WINN WAY | ||||||||
| Address2: | SUITE 221 | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042923810 | ||||||||
| FaxNumber: | 4042923848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 003045 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.