Provider Demographics
NPI:1679609036
Name:JACKSON, ADRIENNE MCGAHEE (LPC)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:MCGAHEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 CHERRY ST.
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-427-7441
Mailing Address - Fax:770-422-2302
Practice Address - Street 1:122 CHERRY ST.
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-427-7441
Practice Address - Fax:770-422-2302
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
GA004539103T00000X
GA04539101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA214383008AMedicaid