Provider Demographics
NPI:1528274636
Name:HARRIS BATHRICK, JESSE M
Entity type:Individual
Prefix:MS
First Name:JESSE
Middle Name:M
Last Name:HARRIS BATHRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 SEMINOLE AVE NE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-3408
Mailing Address - Country:US
Mailing Address - Phone:404-873-6840
Mailing Address - Fax:404-881-8410
Practice Address - Street 1:675 SEMINOLE AVE NE
Practice Address - Street 2:SUITE 107
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-3408
Practice Address - Country:US
Practice Address - Phone:404-873-6840
Practice Address - Fax:404-881-8410
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000439106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000436OtherLICENSE NUMBER