Provider Demographics
NPI:1891250221
Name:HATHORN, JESSICA RAE (MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:HATHORN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 PONCE DE LEON PL NE APT 103
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4152
Mailing Address - Country:US
Mailing Address - Phone:813-362-0340
Mailing Address - Fax:
Practice Address - Street 1:740 CAMERON M ALEXANDER BLVD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-6812
Practice Address - Country:US
Practice Address - Phone:813-362-0340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional