Healthcare Provider Details

I. General information

NPI: 1487134714
Provider Name (Legal Business Name): JESSICA GANT SEXTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BROADWAY AVE
BRASELTON GA
30517
US

IV. Provider business mailing address

PO BOX 637
BRASELTON GA
30517-0011
US

V. Phone/Fax

Practice location:
  • Phone: 470-236-8131
  • Fax:
Mailing address:
  • Phone: 470-236-8131
  • Fax: 706-824-1870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC005141
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: