Provider Demographics
NPI:1669638318
Name:TEAGUE, JENNIFER ELISHA (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELISHA
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W CAMPGROUND RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8002
Mailing Address - Country:US
Mailing Address - Phone:770-898-2966
Mailing Address - Fax:
Practice Address - Street 1:204 W CAMPGROUND RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8002
Practice Address - Country:US
Practice Address - Phone:770-898-2966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005083101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional