Provider Demographics
NPI:1932857794
Name:SIMMONS, JACQUELINE LEE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
Last Name:SIMMONS
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 1:1559 JANMAR RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5606
Mailing Address - Country:US
Mailing Address - Phone:770-336-7373
Mailing Address - Fax:770-336-7374
Practice Address - Street 1:1517 CHERRY HILL RD SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6812
Practice Address - Country:US
Practice Address - Phone:470-709-8742
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician