Provider Demographics
NPI:1164225058
Name:ROBERTS, JACKIE (GCADC-II)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:GCADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 ROBERTS WAY
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-5064
Mailing Address - Country:US
Mailing Address - Phone:706-768-0423
Mailing Address - Fax:
Practice Address - Street 1:592 MEDICAL PARK DR STE A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2055
Practice Address - Country:US
Practice Address - Phone:770-503-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)