Provider Demographics
NPI:1902361553
Name:COSTALES, JON PATRICK (LPC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:PATRICK
Last Name:COSTALES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7339 REINHARDT COLLEGE PKWY
Mailing Address - Street 2:
Mailing Address - City:WALESKA
Mailing Address - State:GA
Mailing Address - Zip Code:30183-2901
Mailing Address - Country:US
Mailing Address - Phone:404-446-7678
Mailing Address - Fax:
Practice Address - Street 1:310 PAPER TRAIL WAY STE 106
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-5204
Practice Address - Country:US
Practice Address - Phone:678-880-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009867101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional