Provider Demographics
NPI:1346383106
Name:PICKENS, JERRY WILLIE (JERRY PICKENS)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WILLIE
Last Name:PICKENS
Suffix:
Gender:M
Credentials:JERRY PICKENS
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:WILLIE
Other - Last Name:PICKENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JERRY PICKENS
Mailing Address - Street 1:2520 PEACHTREE RD NW APT 116
Mailing Address - Street 2:116
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3617
Mailing Address - Country:US
Mailing Address - Phone:404-846-8100
Mailing Address - Fax:
Practice Address - Street 1:2520 PEACHTREE RD NW APT 116
Practice Address - Street 2:116
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3617
Practice Address - Country:US
Practice Address - Phone:404-846-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA204106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist