Provider Demographics
NPI:1700691060
Name:JENNINGS, GRACYN PAIGE WISTOSKI (LPC)
Entity type:Individual
Prefix:
First Name:GRACYN
Middle Name:PAIGE WISTOSKI
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:GRACYN
Other - Middle Name:PAIGE
Other - Last Name:WISTOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APC
Mailing Address - Street 1:327 DAHLONEGA ST STE A601
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2488
Mailing Address - Country:US
Mailing Address - Phone:678-439-1049
Mailing Address - Fax:
Practice Address - Street 1:327 DAHLONEGA ST STE A601
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2488
Practice Address - Country:US
Practice Address - Phone:678-439-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC015777101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional