Healthcare Provider Details

I. General information

NPI: 1144156407
Provider Name (Legal Business Name): MECCA IMANI JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 JOHNSON FERRY RD STE 125
MARIETTA GA
30062-6403
US

IV. Provider business mailing address

2825 S MAIN ST NW APT 246
KENNESAW GA
30144-2754
US

V. Phone/Fax

Practice location:
  • Phone: 678-216-2674
  • Fax:
Mailing address:
  • Phone: 678-216-2674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: