Provider Demographics
NPI:1902562085
Name:GARRETT, DONALD JEROME
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:JEROME
Last Name:GARRETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 REMINGTON AVE APT C
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5686
Mailing Address - Country:US
Mailing Address - Phone:850-661-7384
Mailing Address - Fax:
Practice Address - Street 1:528 REMINGTON AVE APT C
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5686
Practice Address - Country:US
Practice Address - Phone:850-661-7384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1624P-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1624P-MOtherINTERN