Provider Demographics
NPI:1194569459
Name:WORTHEN, DEJAH MALKEEVIA
Entity type:Individual
Prefix:
First Name:DEJAH
Middle Name:MALKEEVIA
Last Name:WORTHEN
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 1:408 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:EAST DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31027-7759
Mailing Address - Country:US
Mailing Address - Phone:478-595-0976
Mailing Address - Fax:
Practice Address - Street 1:1717 RICE AVE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3524
Practice Address - Country:US
Practice Address - Phone:478-279-7214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-24-73585103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst