Provider Demographics
NPI:1073036273
Name:KOALENZ, JESSICA (NCC, APC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KOALENZ
Suffix:
Gender:F
Credentials:NCC, APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ENTERPRISE PATH STE 305-2
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2689
Mailing Address - Country:US
Mailing Address - Phone:678-896-8959
Mailing Address - Fax:
Practice Address - Street 1:107 ENTERPRISE PATH
Practice Address - Street 2:SUITE 305-2
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141
Practice Address - Country:US
Practice Address - Phone:678-896-8959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health