Provider Demographics
NPI:1699578047
Name:BOURNE, CHERYL ANDREA JACKSON
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANDREA JACKSON
Last Name:BOURNE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2862 LIVSEY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2584
Mailing Address - Country:US
Mailing Address - Phone:770-402-1765
Mailing Address - Fax:
Practice Address - Street 1:3072 EARLY ST NW STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1984
Practice Address - Country:US
Practice Address - Phone:404-865-3929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist