Provider Demographics
NPI:1104002831
Name:TALLEY, JESSICA D (LMSW)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:D
Last Name:TALLEY
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 1:8043 CREEKSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3948
Mailing Address - Country:US
Mailing Address - Phone:678-422-5851
Mailing Address - Fax:
Practice Address - Street 1:8043 CREEKSTONE WAY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-3948
Practice Address - Country:US
Practice Address - Phone:678-422-5851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001487104100000X
TX51134104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker