Provider Demographics
NPI:1063717197
Name:JUCKS, PATRICE EUSTACHE (EDD, LPC)
Entity type:Individual
Prefix:DR
First Name:PATRICE
Middle Name:EUSTACHE
Last Name:JUCKS
Suffix:
Gender:F
Credentials:EDD, LPC
Other - Prefix:
Other - First Name:PATRICE
Other - Middle Name:VAUGHN
Other - Last Name:EUSTACHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LPC
Mailing Address - Street 1:4405 NORTHSIDE PKWY NW APT 2414
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-5206
Mailing Address - Country:US
Mailing Address - Phone:770-715-6880
Mailing Address - Fax:
Practice Address - Street 1:2655 DALLAS HWY SW
Practice Address - Street 2:STE 530
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2597
Practice Address - Country:US
Practice Address - Phone:678-919-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005669101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional