Provider Demographics
NPI:1962781401
Name:DYSON, JEROME QUINCY (LCSW)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:QUINCY
Last Name:DYSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 THE EXCHANGE SE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2022
Mailing Address - Country:US
Mailing Address - Phone:678-460-0345
Mailing Address - Fax:678-460-0350
Practice Address - Street 1:1900 THE EXCHANGE SE
Practice Address - Street 2:SUITE 420
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2022
Practice Address - Country:US
Practice Address - Phone:678-460-0345
Practice Address - Fax:678-460-0350
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004440104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker