Provider Demographics
NPI:1114475563
Name:MCCULLY, JASMINE V (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:V
Last Name:MCCULLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90265
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30364-0265
Mailing Address - Country:US
Mailing Address - Phone:219-484-5904
Mailing Address - Fax:888-773-1428
Practice Address - Street 1:1835 SAVOY DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-1072
Practice Address - Country:US
Practice Address - Phone:219-484-5904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2022-08-22
Deactivation Date:2018-04-27
Deactivation Code:
Reactivation Date:2020-03-11
Provider Licenses
StateLicense IDTaxonomies
IN34009515A1041C0700X
MI68011071781041C0700X
IL1490216021041C0700X
GACSW0069901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical