Provider Demographics
NPI:1629625223
Name:JAMES, BETTY JEAN
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:JEAN
Last Name:JAMES
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 1:96 TOMMY STALNAKER DR STE B
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-9236
Mailing Address - Country:US
Mailing Address - Phone:478-333-2735
Mailing Address - Fax:
Practice Address - Street 1:96 TOMMY STALNAKER DR STE B
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9236
Practice Address - Country:US
Practice Address - Phone:478-333-2735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010804101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA208019303Medicaid
GA208019303OtherNONE