Provider Demographics
NPI:1376058404
Name:WHALEN, PATRICIA JACKSON
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JACKSON
Last Name:WHALEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HENDERSON DR STE 220
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-3744
Mailing Address - Country:US
Mailing Address - Phone:470-270-9268
Mailing Address - Fax:770-334-2675
Practice Address - Street 1:650 HENDERSON DR STE 220
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3744
Practice Address - Country:US
Practice Address - Phone:470-270-9268
Practice Address - Fax:770-334-2675
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006206101YP2500X
GAAP00626C101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional