Provider Demographics
NPI:1164822623
Name:SHERIDAN, JESSICA (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHERIDAN
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 1:7855 KAYAK WAY
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-8915
Mailing Address - Country:US
Mailing Address - Phone:678-595-2020
Mailing Address - Fax:470-297-3685
Practice Address - Street 1:104 PILGRIM VILLAGE DR STE 300
Practice Address - Street 2:SUITE 4245
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9232
Practice Address - Country:US
Practice Address - Phone:678-595-2020
Practice Address - Fax:470-297-3685
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW005974101YP2500X
GA0057771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional