Healthcare Provider Details

I. General information

NPI: 1821810433
Provider Name (Legal Business Name): JENNICELE RIVAS APC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2024
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BUFORD HWY STE C1
BUFORD GA
30518-8722
US

IV. Provider business mailing address

110 MANOR WAY
BRASELTON GA
30517-3579
US

V. Phone/Fax

Practice location:
  • Phone: 470-238-9881
  • Fax:
Mailing address:
  • Phone: 770-990-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC016093
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: