Provider Demographics
NPI:1902398027
Name:SULLIVAN, JERMAINE NICHOLAS (NCC)
Entity Type:Individual
Prefix:
First Name:JERMAINE
Middle Name:NICHOLAS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2788 DEFOORS FERRY RD NW APT 333
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2139
Mailing Address - Country:US
Mailing Address - Phone:404-401-6068
Mailing Address - Fax:
Practice Address - Street 1:365 NORTHRIDGE RD STE 310
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-6101
Practice Address - Country:US
Practice Address - Phone:770-771-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health