Healthcare Provider Details

I. General information

NPI: 1376317487
Provider Name (Legal Business Name): JAKETA LEENA GROVES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 MAYFIELD RD STE 203
MILTON GA
30009-3012
US

IV. Provider business mailing address

850 MAYFIELD RD STE 203
MILTON GA
30009-3012
US

V. Phone/Fax

Practice location:
  • Phone: 470-805-5040
  • Fax: 678-268-4550
Mailing address:
  • Phone: 470-805-5040
  • Fax: 678-268-4550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC014112
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: