Provider Demographics
NPI:1871818641
Name:JACOB'S LADDER NEURODEVELOPMENTAL LEARNING CENTER
Entity Type:Organization
Organization Name:JACOB'S LADDER NEURODEVELOPMENTAL LEARNING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'DELL
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC, LAT, CNC
Authorized Official - Phone:770-998-1017
Mailing Address - Street 1:407 HARDSCRABBLE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1417
Mailing Address - Country:US
Mailing Address - Phone:770-998-1017
Mailing Address - Fax:770-998-3258
Practice Address - Street 1:407 HARDSCRABBLE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1417
Practice Address - Country:US
Practice Address - Phone:770-998-1017
Practice Address - Fax:770-998-3258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW006914101YM0800X
GALPC004163101YP2500X, 101YP2500X
GA09634048103TS0200X
GAMSW0067901041C0700X
GAPT0104992251P0200X
GAPT0020012251P0200X
GA1059225XP0200X
GAOT005584225XP0200X
GASLP007882235Z00000X
GA08392225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Multi-Specialty