Provider Demographics
NPI:1174508790
Name:LINDER, JACKLYN P
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:P
Last Name:LINDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3653 LYNNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2841
Mailing Address - Country:US
Mailing Address - Phone:706-860-6805
Mailing Address - Fax:
Practice Address - Street 1:3421 MIKE PADGETT HWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3815
Practice Address - Country:US
Practice Address - Phone:706-432-4760
Practice Address - Fax:706-432-3780
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002352104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2010Medicare ID - Type Unspecified