Healthcare Provider Details

I. General information

NPI: 1669056131
Provider Name (Legal Business Name): JESSICA CHARISE CANTEEN MED, MHC, LPC, CEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5284 FLOYD RD SW UNIT 767
MABLETON GA
30126-6107
US

IV. Provider business mailing address

5284 FLOYD RD SW UNIT 767
MABLETON GA
30126-6107
US

V. Phone/Fax

Practice location:
  • Phone: 678-460-6334
  • Fax:
Mailing address:
  • Phone: 678-460-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC.LH.61356267
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC014914
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC012698
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00880500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: