Provider Demographics
NPI:1730232521
Name:THOMAS, JERRY VINCENT (LPC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:VINCENT
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3047 HUDSON CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-1115
Mailing Address - Country:US
Mailing Address - Phone:404-587-8707
Mailing Address - Fax:404-633-4403
Practice Address - Street 1:4001 PRESIDENTIAL PKWY
Practice Address - Street 2:700
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-3719
Practice Address - Country:US
Practice Address - Phone:404-587-8707
Practice Address - Fax:404-633-4403
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4299101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional