Provider Demographics
NPI:1578119178
Name:POGUE, JARED (MED, LPC)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:POGUE
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 QUEEN ST SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-2611
Mailing Address - Country:US
Mailing Address - Phone:770-595-6924
Mailing Address - Fax:
Practice Address - Street 1:687 QUEEN ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-2611
Practice Address - Country:US
Practice Address - Phone:770-595-6924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010265101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional