Provider Demographics
NPI:1265830954
Name:JACKSON, CHEMARA (EDD, LPC)
Entity type:Individual
Prefix:
First Name:CHEMARA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:EDD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 LOCHERBY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4385
Mailing Address - Country:US
Mailing Address - Phone:404-754-2989
Mailing Address - Fax:
Practice Address - Street 1:4845 LOCHERBY DR
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-4385
Practice Address - Country:US
Practice Address - Phone:404-754-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-11
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140046AMedicaid