Provider Demographics
NPI:1518616424
Name:O'GORMAN, JENNIFER (APC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:O'GORMAN
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 TOWNE LAKE HTS
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4227
Mailing Address - Country:US
Mailing Address - Phone:678-545-9728
Mailing Address - Fax:
Practice Address - Street 1:203 OAKSIDE LN STE F
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-6407
Practice Address - Country:US
Practice Address - Phone:678-545-9728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-20
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GAAPC009403101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health