Healthcare Provider Details

I. General information

NPI: 1871818641
Provider Name (Legal Business Name): JACOB'S LADDER NEURODEVELOPMENTAL LEARNING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 HARDSCRABBLE RD
ROSWELL GA
30075-1417
US

IV. Provider business mailing address

407 HARDSCRABBLE RD
ROSWELL GA
30075-1417
US

V. Phone/Fax

Practice location:
  • Phone: 770-998-1017
  • Fax: 770-998-3258
Mailing address:
  • Phone: 770-998-1017
  • Fax: 770-998-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMSW006914
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC004163
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number09634048
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMSW006790
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT010499
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT002001
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1059
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT005584
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP007882
License Number StateGA

VIII. Authorized Official

Name: AMY O'DELL
Title or Position: FOUNDER/DIRECTOR
Credential: M.ED, LPC, LAT, CNC
Phone: 770-998-1017