Provider Demographics
NPI:1255944187
Name:BAKER, JESSICA AQUILLA (LCSW)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:AQUILLA
Last Name:BAKER
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 1:332 PROVIDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-9705
Mailing Address - Country:US
Mailing Address - Phone:478-746-1438
Mailing Address - Fax:
Practice Address - Street 1:332 PROVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-9705
Practice Address - Country:US
Practice Address - Phone:478-746-1438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-29
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0069651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical