Basic Information
| Provider Information | |||||||||
| NPI: | 1073818845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JERI | ||||||||
| MiddleName: | SANSOM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANSOM | ||||||||
| OtherFirstName: | JERI | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5400 LAUREL SPRINGS PKWY STE 602 | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300246067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782132194 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5400 LAUREL SPRINGS PKWY STE 602 | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300246067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782132194 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2011 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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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 | 101YP2500X | LPC004176 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.