Provider Demographics
NPI:1215381850
Name:LOVE, JACQUELINE NICHELE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICHELE
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 PRESIDENTIAL PKWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-3705
Mailing Address - Country:US
Mailing Address - Phone:404-438-6433
Mailing Address - Fax:
Practice Address - Street 1:2788 DEFOORS FERRY RD NW
Practice Address - Street 2:43
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2182
Practice Address - Country:US
Practice Address - Phone:404-438-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008650101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional