Provider Demographics
NPI:1285706960
Name:LUCKOW FOX, JAYMIE HELEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAYMIE
Middle Name:HELEN
Last Name:LUCKOW FOX
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JAYMIE
Other - Middle Name:HELEN
Other - Last Name:LUCKOW FOX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4674 HOWELL FARMS DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8833
Mailing Address - Country:US
Mailing Address - Phone:678-923-6795
Mailing Address - Fax:
Practice Address - Street 1:2308 PERIMETER PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-1316
Practice Address - Country:US
Practice Address - Phone:770-457-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002999103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA380415072AMedicaid