NPIMap

Organization Active NPI

Jehovahs Behavioral Care LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Dacula, GA
National Provider Identifier
1619612876
Registry record updated Nov 15, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X
Legal business name
JEHOVAHS BEHAVIORAL CARE LLC
Practice address
3206 Thimbleberry TRL
Dacula, GA 30019-7299
Phone
(404) 819-7338
NPI assigned
May 2, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 15, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Grace Fomunung, PMHNPNPI 1679028575
Title
Manager
Phone
(404) 819-7338

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Health Service Clinic/Center 261QH0100X
Adult Mental Health Clinic/Center 261QM0850X
Adolescent and Children Mental Health Clinic/Center 261QM0855X
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X Primary

Addresses

Primary practice location

3206 Thimbleberry TRL
Dacula, GA 30019-7299

Mailing address

4652 Lawrenceville Hwy NW
Lilburn, GA 30047-3621
Phone (404) 819-7338

Other names 1

  • GRACE FOMUNUNG SOLE MBR Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220908001795 GA Part B Supplier - Clinic/Group Practice 0840674974 Receives reassigned benefits from 2 practitioners
Practice locations: Lilburn, GA

National Provider Directory

National Provider Directory

Locations

4652 Lawrenceville Hwy NW
Ste 101
Lilburn, GA 30047
Phone (678) 314-5299

4652 Lawrenceville Hwy NW
Lilburn, GA 30047

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1651449600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1668470400000",
    "number": "1619612876",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4652 LAWRENCEVILLE HWY NW",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300473621",
            "telephone_number": "404-819-7338"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3206 THIMBLEBERRY TRL",
            "city": "DACULA",
            "state": "GA",
            "postal_code": "300197299",
            "telephone_number": "404-819-7338"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEHOVAHS BEHAVIORAL CARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-05-02",
        "last_updated": "2022-11-15",
        "certification_date": "2022-11-15",
        "status": "A",
        "authorized_official_last_name": "FOMUNUNG",
        "authorized_official_first_name": "GRACE",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "404-819-7338",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "PMHNP"
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "GRACE FOMUNUNG SOLE MBR",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "GRACE FOMUNUNG SOLE MBR",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dacula, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.