Provider Demographics
NPI:1356680268
Name:GOSWICK, JIMMIE CALLAHAN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JIMMIE
Middle Name:CALLAHAN
Last Name:GOSWICK
Suffix:
Gender:F
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:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703-0213
Mailing Address - Country:US
Mailing Address - Phone:706-602-0339
Mailing Address - Fax:706-602-9359
Practice Address - Street 1:654 RED BUD RD NE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-1963
Practice Address - Country:US
Practice Address - Phone:706-602-0339
Practice Address - Fax:706-602-9359
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002963101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA487392351AMedicaid