Provider Demographics
NPI:1275990756
Name:PARKS, JEANIE (BA, MED)
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:BA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:868 CHESAPEAKE WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-7336
Mailing Address - Country:US
Mailing Address - Phone:404-565-3776
Mailing Address - Fax:
Practice Address - Street 1:868 CHESAPEAKE WAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-7336
Practice Address - Country:US
Practice Address - Phone:404-565-3776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health