Provider Demographics
NPI:1730230996
Name:HENRIQUES, JAN H (AUD)
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:H
Last Name:HENRIQUES
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 WOODPARK PLACE
Mailing Address - Street 2:SUITE B-100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188
Mailing Address - Country:US
Mailing Address - Phone:770-560-4775
Mailing Address - Fax:770-234-6977
Practice Address - Street 1:203 WOODPARK PLACE
Practice Address - Street 2:SUITE B-100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:770-560-4775
Practice Address - Fax:770-234-6977
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1690231H00000X
GA001690237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000876752AMedicaid
GA000784506AMedicaid
GAS53169Medicare UPIN
GAX67534Medicare UPIN
GA000784506AMedicaid
GAGRP4289Medicare UPIN