Provider Demographics
NPI:1417231648
Name:STUCKERT, JENNIFER L (MFT, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:STUCKERT
Suffix:
Gender:F
Credentials:MFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 COLONIAL PARK DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3760
Mailing Address - Country:US
Mailing Address - Phone:678-534-3824
Mailing Address - Fax:678-534-3824
Practice Address - Street 1:595 COLONIAL PARK DR STE 102
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3760
Practice Address - Country:US
Practice Address - Phone:678-534-3824
Practice Address - Fax:678-534-3824
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004704101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional