Provider Demographics
NPI:1215373485
Name:UNDERWOOD, JACK (MS, NCC, LPC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-1567
Mailing Address - Country:US
Mailing Address - Phone:404-421-5341
Mailing Address - Fax:
Practice Address - Street 1:3108 PIEDMONT RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2513
Practice Address - Country:US
Practice Address - Phone:404-421-5341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007057101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional