Provider Demographics
NPI:1891250718
Name:JEAN GOLDTHWAIT LCSW
Entity Type:Organization
Organization Name:JEAN GOLDTHWAIT LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GOLDTHWAIT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:315-744-0765
Mailing Address - Street 1:755 BELLE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-6026
Mailing Address - Country:US
Mailing Address - Phone:315-744-0765
Mailing Address - Fax:912-455-4955
Practice Address - Street 1:9390 FORD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-6421
Practice Address - Country:US
Practice Address - Phone:315-744-0765
Practice Address - Fax:912-445-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)