Basic Information
| Provider Information | |||||||||
| NPI: | 1114372455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 WINN WAY | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045087796 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12 EXECUTIVE PARK DR NE # 200 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047270010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2016 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 80709 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.