Basic Information
| Provider Information | |||||||||
| NPI: | 1114270998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROE | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | STEWART | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 FOUNTAIN DR | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300787022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709856473 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2160 FOUNTAIN DR | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300787022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709856473 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2012 | ||||||||
| LastUpdateDate: | 02/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1017-2376C | AL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | CSW006940 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.