Provider Demographics
NPI:1730466780
Name:MERRILL, JENNIFER WALLACE (LAPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WALLACE
Last Name:MERRILL
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HANDLEY RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2177
Mailing Address - Country:US
Mailing Address - Phone:770-486-1011
Mailing Address - Fax:
Practice Address - Street 1:120 HANDLEY RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2177
Practice Address - Country:US
Practice Address - Phone:770-486-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC002988101YM0800X
GALPC007657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health