Provider Demographics
NPI:1699101147
Name:JIMMY'S MAGNOLIA TREE INC
Entity type:Organization
Organization Name:JIMMY'S MAGNOLIA TREE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-748-9276
Mailing Address - Street 1:1526 WESTWOOD AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-2316
Mailing Address - Country:US
Mailing Address - Phone:404-748-9276
Mailing Address - Fax:
Practice Address - Street 1:1526 WESTWOOD AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-2316
Practice Address - Country:US
Practice Address - Phone:404-748-9276
Practice Address - Fax:404-941-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACLA001050251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA972175212AOtherCOMP WAVIER