Provider Demographics
NPI:1467863308
Name:MATHISEN, JESSICA LAUREN (LPC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LAUREN
Last Name:MATHISEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30077-0523
Mailing Address - Country:US
Mailing Address - Phone:214-425-4448
Mailing Address - Fax:
Practice Address - Street 1:800 OLD ROSWELL LAKES PKWY
Practice Address - Street 2:SUITE 260
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1675
Practice Address - Country:US
Practice Address - Phone:214-425-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007311101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional