Provider Demographics
NPI:1184792319
Name:JURKOVIC, GREGORY JAMES (PHD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JAMES
Last Name:JURKOVIC
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 WILLOW BND
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4640
Mailing Address - Country:US
Mailing Address - Phone:404-401-1778
Mailing Address - Fax:
Practice Address - Street 1:1513 JOHNSON FERRY RD
Practice Address - Street 2:SUITE T-1
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8101
Practice Address - Country:US
Practice Address - Phone:770-578-1744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0627103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical