Provider Demographics
NPI:1972114643
Name:SHAIN, JEREMY DANIEL (LPC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DANIEL
Last Name:SHAIN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-2212
Mailing Address - Country:US
Mailing Address - Phone:404-512-4030
Mailing Address - Fax:
Practice Address - Street 1:101 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-2212
Practice Address - Country:US
Practice Address - Phone:404-512-4030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional