Provider Demographics
NPI:1407268444
Name:GRIZZELL, JONATHAN MARK (LPC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARK
Last Name:GRIZZELL
Suffix:
Gender:M
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 1203
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-0021
Mailing Address - Country:US
Mailing Address - Phone:706-633-9319
Mailing Address - Fax:
Practice Address - Street 1:89 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-9669
Practice Address - Country:US
Practice Address - Phone:706-636-1386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-26
Last Update Date:2014-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007805101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional