Provider Demographics
NPI:1760292221
Name:GARY, JC III
Entity type:Individual
Prefix:MR
First Name:JC
Middle Name:
Last Name:GARY
Suffix:III
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 1:1070 CREST LINE DR
Mailing Address - Street 2:
Mailing Address - City:UPATOI
Mailing Address - State:GA
Mailing Address - Zip Code:31829-1796
Mailing Address - Country:US
Mailing Address - Phone:706-575-5245
Mailing Address - Fax:
Practice Address - Street 1:1070 CREST LINE DR
Practice Address - Street 2:
Practice Address - City:UPATOI
Practice Address - State:GA
Practice Address - Zip Code:31829-1796
Practice Address - Country:US
Practice Address - Phone:706-575-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1131042106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician