Provider Demographics
NPI:1578017166
Name:GROGG, JEREMIAH (MS, LPC)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:
Last Name:GROGG
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N BELAIR SQ STE 2
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809
Mailing Address - Country:US
Mailing Address - Phone:706-836-1195
Mailing Address - Fax:844-873-4758
Practice Address - Street 1:601 N BELAIR SQ STE 2
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-0518
Practice Address - Country:US
Practice Address - Phone:706-836-1195
Practice Address - Fax:844-873-4758
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181469AMedicaid