Provider Demographics
NPI:1710561501
Name:JACQUES, AMY (LPC, BC-DMT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:LPC, BC-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3446 WINDER HWY STE M
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3002
Mailing Address - Country:US
Mailing Address - Phone:678-632-6169
Mailing Address - Fax:678-943-1197
Practice Address - Street 1:610 CANDLER ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3334
Practice Address - Country:US
Practice Address - Phone:678-632-6169
Practice Address - Fax:678-943-1197
Is Sole Proprietor?:No
Enumeration Date:2021-05-08
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012102101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional