Provider Demographics
NPI:1528029089
Name:ANDERSON, STACY JAYNES (MED, LPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JAYNES
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 PRESTLEY MILL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2288
Mailing Address - Country:US
Mailing Address - Phone:770-949-9675
Mailing Address - Fax:770-949-9676
Practice Address - Street 1:6130 PRESTLEY MILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2288
Practice Address - Country:US
Practice Address - Phone:770-949-9675
Practice Address - Fax:770-949-9676
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004243101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health