Provider Demographics
NPI:1003253253
Name:JESSE, MICHELLE THERESA (PHD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESA
Last Name:JESSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE STE 420
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1171
Mailing Address - Country:US
Mailing Address - Phone:770-514-6760
Mailing Address - Fax:770-794-8034
Practice Address - Street 1:55 WHITCHER ST NE STE 420
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1171
Practice Address - Country:US
Practice Address - Phone:770-514-6760
Practice Address - Fax:770-794-8034
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004749103TC0700X
MI6301014633103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical