Provider Demographics
NPI:1316363393
Name:JACKSON, JUANITA (MS, LPC)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
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 1:1434 PACES COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1725
Mailing Address - Country:US
Mailing Address - Phone:706-402-3091
Mailing Address - Fax:
Practice Address - Street 1:1206 FRANKLIN PKWY
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:GA
Practice Address - Zip Code:30217-7508
Practice Address - Country:US
Practice Address - Phone:706-675-6399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003710101YM0800X
GALPC009547101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health