Healthcare Provider Details

I. General information

NPI: 1366306136
Provider Name (Legal Business Name): THE OLIVE HAVEN COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 WILLS WAY
GRIFFIN GA
30223-8799
US

IV. Provider business mailing address

118 WILLS WAY
GRIFFIN GA
30223-8799
US

V. Phone/Fax

Practice location:
  • Phone: 470-402-2226
  • Fax:
Mailing address:
  • Phone: 470-402-2226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHAYLON JACKSON
Title or Position: OWNER
Credential: LPC
Phone: 678-814-7559