Healthcare Provider Details

I. General information

NPI: 1538092572
Provider Name (Legal Business Name): MARKELLILA JORDAN LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 LAUREL DR STE 8
COLUMBUS GA
31907-2694
US

IV. Provider business mailing address

2217 LAUREL DR STE 8
COLUMBUS GA
31907-2694
US

V. Phone/Fax

Practice location:
  • Phone: 706-593-4897
  • Fax: 706-243-6454
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC011372
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: