Provider Demographics
NPI:1265596274
Name:JETT, DAWN MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MICHELLE
Last Name:JETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5338
Mailing Address - Country:US
Mailing Address - Phone:706-951-2182
Mailing Address - Fax:706-364-0401
Practice Address - Street 1:3540 WHEELER RD STE 210
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1879
Practice Address - Country:US
Practice Address - Phone:706-951-2182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0032211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I801495Medicare UPIN