Provider Demographics
NPI:1467920975
Name:EDGE, JENNIFER (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:EDGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:EDGECARE
Other - Middle Name:
Other - Last Name:360 LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:224 WINDY HILL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8430
Mailing Address - Country:US
Mailing Address - Phone:770-933-5328
Mailing Address - Fax:470-980-0507
Practice Address - Street 1:2470 WINDY HILL RD SE STE 300
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8621
Practice Address - Country:US
Practice Address - Phone:770-933-5328
Practice Address - Fax:470-980-0507
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YP2500X, 103TB0200X, 103TP2701X, 172V00000X
CSW007295103TC1900X
GACSW0072951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No172V00000XOther Service ProvidersCommunity Health Worker