Basic Information
Provider Information | |||||||||
NPI: | 1730281163 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POWELL | ||||||||
FirstName: | JEANNIE | ||||||||
MiddleName: | O | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OGLESBY | ||||||||
OtherFirstName: | JEANNIE | ||||||||
OtherMiddleName: | B | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 179 PIERCE AVE | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312042821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4887421464 | ||||||||
FaxNumber: | 4787421883 | ||||||||
Practice Location | |||||||||
Address1: | 179 PIERCE AVE | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312042821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4887421464 | ||||||||
FaxNumber: | 4787421883 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2006 | ||||||||
LastUpdateDate: | 08/26/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 004182 | GA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 931984159A | 05 | GA |   | MEDICAID |