Provider Demographics
NPI:1609231414
Name:JACKSON, CHERLISA (MA, MPH, LPC, CHES)
Entity Type:Individual
Prefix:MISS
First Name:CHERLISA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, MPH, LPC, CHES
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 311733
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31131-1733
Mailing Address - Country:US
Mailing Address - Phone:470-440-0058
Mailing Address - Fax:
Practice Address - Street 1:5835 CAMPBELLTON RD SW STE 102
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8014
Practice Address - Country:US
Practice Address - Phone:470-440-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004613101YP2500X
GALPC011598101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty