=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306109665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAKETRA BRYANT LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2012
-----------------------------------------------------
Last Update Date | 02/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1230 PEACHTREE ROAD SUITE 1900
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-942-3320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1230 PEACHTREE RD SUITE 1900
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-942-3320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | APC002807
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC007645
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------