Provider Demographics
NPI:1013249846
Name:ROOT, JESSICA DIANE (LPCA)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DIANE
Last Name:ROOT
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CHADWYCK LN
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3151
Mailing Address - Country:US
Mailing Address - Phone:478-971-4684
Mailing Address - Fax:478-971-4685
Practice Address - Street 1:306 CORDER RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3647
Practice Address - Country:US
Practice Address - Phone:478-971-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006368101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health