Provider Demographics
NPI:1326442922
Name:JETT, LAKEACHA M
Entity Type:Individual
Prefix:DR
First Name:LAKEACHA
Middle Name:M
Last Name:JETT
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 1:155 HUMBOLDT DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2026
Mailing Address - Country:US
Mailing Address - Phone:404-953-2590
Mailing Address - Fax:
Practice Address - Street 1:124 S MAIN ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3599
Practice Address - Country:US
Practice Address - Phone:404-953-2590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health