Provider Demographics
NPI:1245358852
Name:SHIAU, JEANIE WITCRAFT (LCSW)
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:WITCRAFT
Last Name:SHIAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12095 CRABAPPLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4260
Mailing Address - Country:US
Mailing Address - Phone:678-809-5835
Mailing Address - Fax:
Practice Address - Street 1:1007 MANSELL RD STE A107
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5019
Practice Address - Country:US
Practice Address - Phone:678-667-1673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW46471041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA330739Medicaid
GA1962891853OtherNPPES