Provider Demographics
NPI:1417793696
Name:EASTON, KJESTI (MA)
Entity type:Individual
Prefix:
First Name:KJESTI
Middle Name:
Last Name:EASTON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KJESTI
Other - Middle Name:SUE
Other - Last Name:JOHNSON EASTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1490 CRAWLEY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-2265
Mailing Address - Country:US
Mailing Address - Phone:706-424-3644
Mailing Address - Fax:
Practice Address - Street 1:105 WHITEHEAD RD STE 6
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-1551
Practice Address - Country:US
Practice Address - Phone:706-424-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC00819101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional