Provider Demographics
NPI:1881146397
Name:BURNS JACKSON, WANDA (LPC)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:
Last Name:BURNS JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:JULIETTE
Mailing Address - State:GA
Mailing Address - Zip Code:31046-4073
Mailing Address - Country:US
Mailing Address - Phone:478-960-0222
Mailing Address - Fax:
Practice Address - Street 1:20 WILLOW WAY
Practice Address - Street 2:
Practice Address - City:JULIETTE
Practice Address - State:GA
Practice Address - Zip Code:31046-4073
Practice Address - Country:US
Practice Address - Phone:478-960-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007202101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional