Provider Demographics
NPI:1265657910
Name:JACKSON, SHANNA DAWN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:DAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 IVERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2076
Mailing Address - Country:US
Mailing Address - Phone:404-254-2847
Mailing Address - Fax:404-254-5871
Practice Address - Street 1:1900 CENTURY PL NE
Practice Address - Street 2:STE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-4307
Practice Address - Country:US
Practice Address - Phone:404-934-9957
Practice Address - Fax:404-254-5871
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004052101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional