Provider Demographics
NPI:1912677535
Name:JORDAN, VENETIA T (MS, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:VENETIA
Middle Name:T
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:VENETIA
Other - Middle Name:T
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3438 FANNIN DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2829
Mailing Address - Country:US
Mailing Address - Phone:678-756-7497
Mailing Address - Fax:
Practice Address - Street 1:678 TOM BREWER RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4005
Practice Address - Country:US
Practice Address - Phone:770-554-3599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012422101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional