Provider Demographics
NPI:1669097895
Name:JEAN-LOUIS, KEDY ERNST
Entity type:Individual
Prefix:
First Name:KEDY
Middle Name:ERNST
Last Name:JEAN-LOUIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2483 HERITAGE VLG STE 16-225
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6140
Mailing Address - Country:US
Mailing Address - Phone:678-524-9477
Mailing Address - Fax:
Practice Address - Street 1:1626 JEURGENS CT
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2219
Practice Address - Country:US
Practice Address - Phone:678-524-9477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0068061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW006806OtherLCSW