Provider Demographics
NPI:1639231251
Name:JAMGOTCHIAN, KIRK N (ICADC)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:N
Last Name:JAMGOTCHIAN
Suffix:
Gender:M
Credentials:ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 DEERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-5010
Mailing Address - Country:US
Mailing Address - Phone:770-838-1420
Mailing Address - Fax:
Practice Address - Street 1:113 - B NEWNAN STREET
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-214-5066
Practice Address - Fax:770-214-5067
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAICADC 24574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)