Basic Information
| Provider Information | |||||||||
| NPI: | 1831633262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBINSON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | NYESHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2935 ROSEBUD RD | ||||||||
| Address2: | UNIT 1708 | ||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300523069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045732093 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 GWINNETT DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782092394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2016 | ||||||||
| LastUpdateDate: | 12/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LPC008787 | GA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC008787 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.