Healthcare Provider Details

I. General information

NPI: 1598039109
Provider Name (Legal Business Name): JESSIE YEARTA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 WALDREP CIR SE
MARIETTA GA
30060-4927
US

IV. Provider business mailing address

1845 WALDREP CIR SE
MARIETTA GA
30060-4927
US

V. Phone/Fax

Practice location:
  • Phone: 770-432-6388
  • Fax:
Mailing address:
  • Phone: 770-432-6388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005242
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: