Provider Demographics
NPI:1376604165
Name:JEAN-JACQUES, ANNELLE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:ANNELLE
Middle Name:
Last Name:JEAN-JACQUES
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 1:5005 SUNBROOK WAY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8031
Mailing Address - Country:US
Mailing Address - Phone:770-974-1061
Mailing Address - Fax:770-974-8354
Practice Address - Street 1:5005 SUNBROOK WAY NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8031
Practice Address - Country:US
Practice Address - Phone:770-974-1061
Practice Address - Fax:770-974-8354
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW002232171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10041078OtherAMERIGROUP PRACTITIONER #
GA00809366BMedicaid
GA10041079OtherAMERIGROUP PRACTITIONER #