Provider Demographics
NPI:1053413963
Name:IRWIN, JACQUELINE (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:IRWIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2281 BRIANWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-1719
Mailing Address - Country:US
Mailing Address - Phone:404-667-7267
Mailing Address - Fax:
Practice Address - Street 1:1493 LAVISTA RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3846
Practice Address - Country:US
Practice Address - Phone:404-667-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0003341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBBJGMedicare ID - Type UnspecifiedCSW