Basic Information
| Provider Information | |||||||||
| NPI: | 1750506952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOPKINS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | BREWER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310154249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292760100 | ||||||||
| FaxNumber: | 2292760300 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310154249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292760100 | ||||||||
| FaxNumber: | 2292760300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC4517 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 614588062A | 05 | GA | MEDICAID |