Provider Demographics
NPI:1730886268
Name:HENRY, JUSTIN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 LAKE OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:WHITE
Mailing Address - State:GA
Mailing Address - Zip Code:30184-4812
Mailing Address - Country:US
Mailing Address - Phone:770-490-0548
Mailing Address - Fax:
Practice Address - Street 1:1810 MULKEY RD STE 202
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1150
Practice Address - Country:US
Practice Address - Phone:770-694-6349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222607363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health