Provider Demographics
NPI:1073159034
Name:JODESTY-JACKSON, MAGDALA TULCIE (LMSW)
Entity Type:Individual
Prefix:
First Name:MAGDALA
Middle Name:TULCIE
Last Name:JODESTY-JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BROWNHILL CT
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2659
Mailing Address - Country:US
Mailing Address - Phone:404-784-6774
Mailing Address - Fax:
Practice Address - Street 1:4343 SHALLOWORD ROAD
Practice Address - Street 2:BUILDING H, SUITE 4 LOWER LEVEL
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:678-694-1573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0048571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical