Provider Demographics
NPI:1003482100
Name:JACOB, GISELLE AMARIS (MS)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:AMARIS
Last Name:JACOB
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 13TH ST NE APT 107
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1244 CLAIRMONT RD STE 204
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1263
Practice Address - Country:US
Practice Address - Phone:404-818-6535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health