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General NPI Number Information
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NPI Number | 1669056131
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Entity Type | Individual
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Provider Name | JESSICA CHARISE CANTEEN MED, MHC, LPC, CEP
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Gender | Female
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Dates
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Enumeration Date | 05/10/2021
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Last Update Date | 01/18/2025
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Provider Practice Location Address
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Address Line | 5284 FLOYD RD SW UNIT 767
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City | MABLETON
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State | GA
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Zip | 30126-6107
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Country | US
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Telephone | 678-460-6334
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Fax |
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Provider Business Mailing Address
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Address Line | 5284 FLOYD RD SW UNIT 767
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City | MABLETON
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State | GA
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Zip | 30126-6107
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Country | US
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Telephone | 678-460-6334
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 37PC00880500
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LH61356267
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | PC014914
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC012698
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License Number State | GA
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