Provider Demographics
NPI:1073818845
Name:GREEN, JERI SANSOM (MS, LPC)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:SANSOM
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:JERI
Other - Middle Name:DAWN
Other - Last Name:SANSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:5400 LAUREL SPRINGS PKWY STE 602
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6067
Mailing Address - Country:US
Mailing Address - Phone:678-213-2194
Mailing Address - Fax:
Practice Address - Street 1:5400 LAUREL SPRINGS PKWY STE 602
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6067
Practice Address - Country:US
Practice Address - Phone:678-213-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004176101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional