Provider Demographics
NPI:1083017743
Name:WALKER, JERRELL (LPC)
Entity Type:Individual
Prefix:MR
First Name:JERRELL
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 SUGARLOAF PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-9402
Mailing Address - Country:US
Mailing Address - Phone:770-676-0589
Mailing Address - Fax:
Practice Address - Street 1:2090 SUGARLOAF PKWY STE 115
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-9402
Practice Address - Country:US
Practice Address - Phone:770-658-4833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007754101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003153183BMedicaid