MEDICARE: MRS. JENNIFER SHEA LASITER LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC003509	GA

General Provider Information

NPI Number	:	1487000527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER SHEA LASITER LPC

Provider Business Mailing Address
First Line	:	514 W BANKHEAD HWY STE 100
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180-1737
Country	:	US
Telephone Number	:	678-941-3868
Fax Number	:

Provider Business Practice Location Address
First Line	:	514 W BANKHEAD HWY STE 100
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180-1737
Country	:	US
Telephone Number	:	678-941-3868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2016
Last Update Date	:	05/09/2016

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