Provider Demographics
NPI:1245688241
Name:SUDDERTH, JENNIFER SCOTT (LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SCOTT
Last Name:SUDDERTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 HEWELL RD NW
Mailing Address - Street 2:
Mailing Address - City:DEWY ROSE
Mailing Address - State:GA
Mailing Address - Zip Code:30634-2956
Mailing Address - Country:US
Mailing Address - Phone:706-371-4020
Mailing Address - Fax:
Practice Address - Street 1:745 S MILLEDGE AVE STE A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-1291
Practice Address - Country:US
Practice Address - Phone:770-389-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012819101YP2500X
GALPC012819101YP2500X
SC7371101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional