Provider Demographics
NPI:1083772495
Name:GREEN, JACQUELINE B (LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:B
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2913 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2069
Mailing Address - Country:US
Mailing Address - Phone:229-245-7009
Mailing Address - Fax:866-738-7755
Practice Address - Street 1:2517 BEMISS RD
Practice Address - Street 2:SUITE C-1
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1963
Practice Address - Country:US
Practice Address - Phone:229-245-0330
Practice Address - Fax:866-738-7755
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001586101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health