Healthcare Provider Details

I. General information

NPI: 1518322395
Provider Name (Legal Business Name): JAQUITA SHORTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 11/08/2020
Certification Date: 11/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 PENNSLYVANIA AVE
MCDONOUGH GA
30252
US

IV. Provider business mailing address

9109 BOSTON HARBOR WAY
MCDONOUGH GA
30252-8951
US

V. Phone/Fax

Practice location:
  • Phone: 678-853-5849
  • Fax:
Mailing address:
  • Phone: 770-378-4917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC010510
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT001529
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: