Provider Demographics
NPI:1700268265
Name:TILLERY, JENNIFER CUMMINGS (LPC, NCC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:CUMMINGS
Last Name:TILLERY
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 SHEPARD DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1560
Mailing Address - Country:US
Mailing Address - Phone:404-433-6153
Mailing Address - Fax:
Practice Address - Street 1:5150 STILESBORO RD NW
Practice Address - Street 2:SUITE 430
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7744
Practice Address - Country:US
Practice Address - Phone:404-433-6153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008457101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional