Healthcare Provider Details

I. General information

NPI: 1710590013
Provider Name (Legal Business Name): JESSICA COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 SHALLOWFORD RD STE 410
MARIETTA GA
30062-5067
US

IV. Provider business mailing address

800 GALLERIA PKWY SE UNIT 319
ATLANTA GA
30339-6003
US

V. Phone/Fax

Practice location:
  • Phone: 678-740-3757
  • Fax:
Mailing address:
  • Phone: 804-495-5190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC015406
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: