Provider Demographics
NPI:1942332887
Name:JEAN, LEANN GAIL (LPC)
Entity Type:Individual
Prefix:MS
First Name:LEANN
Middle Name:GAIL
Last Name:JEAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:LEANN
Other - Middle Name:GAIL
Other - Last Name:OLDFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:3711 EXECUTIVE CENTER DRIVE SUITE 201
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0951
Mailing Address - Country:US
Mailing Address - Phone:706-955-9224
Mailing Address - Fax:706-955-9349
Practice Address - Street 1:3711 EXECUTIVE CENTER DRIVE SUITE 201
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0951
Practice Address - Country:US
Practice Address - Phone:706-955-9224
Practice Address - Fax:706-955-9349
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004416101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA527365613AMedicaid