Provider Demographics
NPI:1184045767
Name:GODWIN, CHASE JACKSON (LPC)
Entity Type:Individual
Prefix:MR
First Name:CHASE
Middle Name:JACKSON
Last Name:GODWIN
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 1:3903 TROTTERS RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-4894
Mailing Address - Country:US
Mailing Address - Phone:912-288-4880
Mailing Address - Fax:
Practice Address - Street 1:3903 TROTTERS RIDGE CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-4894
Practice Address - Country:US
Practice Address - Phone:912-288-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007195101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional