Provider Demographics
NPI:1194455964
Name:REGISTER, JERRY MITCHELL JR (LCSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MITCHELL
Last Name:REGISTER
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3338 COUNTRY CLUB RD # 270
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-1044
Mailing Address - Country:US
Mailing Address - Phone:229-333-2273
Mailing Address - Fax:229-504-5403
Practice Address - Street 1:2935 N ASHLEY ST BLDG F
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1777
Practice Address - Country:US
Practice Address - Phone:229-333-2273
Practice Address - Fax:229-506-5403
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0081061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical