Provider Demographics
NPI:1104098987
Name:MADDOX, JEANETTA RENA (MSW)
Entity type:Individual
Prefix:
First Name:JEANETTA
Middle Name:RENA
Last Name:MADDOX
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 SOMERVILLE RD SE STE 1
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4309
Mailing Address - Country:US
Mailing Address - Phone:256-260-7361
Mailing Address - Fax:256-355-6092
Practice Address - Street 1:1307 E ELM ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-5318
Practice Address - Country:US
Practice Address - Phone:256-232-3661
Practice Address - Fax:256-355-6092
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
51547790OtherBCBS