Provider Demographics
NPI:1811414964
Name:PACKMAN, JESSICA LAUREN (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:PACKMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 STONE PARK DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30188-1625
Mailing Address - Country:US
Mailing Address - Phone:404-281-7189
Mailing Address - Fax:
Practice Address - Street 1:11675 CENTURY DR UNIT C
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-8367
Practice Address - Country:US
Practice Address - Phone:678-740-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW61921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty