Healthcare Provider Details

I. General information

NPI: 1467920975
Provider Name (Legal Business Name): JENNIFER EDGE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EDGECARE 360 LLC LCSW

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 WINDY HILL RD SE STE 300
MARIETTA GA
30067-8621
US

IV. Provider business mailing address

224 WINDY HILL RD SUITE 300
MARIETTA GA
30067-8430
US

V. Phone/Fax

Practice location:
  • Phone: 770-933-5328
  • Fax: 470-980-0507
Mailing address:
  • Phone: 770-933-5328
  • Fax: 470-980-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberCSW007295
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW007295
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: