Provider Demographics
NPI:1225368152
Name:FENNELL, JOSEPH J II (LPC)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:J
Last Name:FENNELL
Suffix:II
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5385
Mailing Address - Country:US
Mailing Address - Phone:912-489-7590
Mailing Address - Fax:912-489-3877
Practice Address - Street 1:19 CHURCH ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5385
Practice Address - Country:US
Practice Address - Phone:912-489-7590
Practice Address - Fax:912-489-3877
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-26
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC001843101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA690639OtherWELLCARE
GA01422484OtherAMERIGROUP