Provider Demographics
NPI:1487242335
Name:WALL, JACKIE HORNBECK (LPC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:HORNBECK
Last Name:WALL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-5205
Mailing Address - Country:US
Mailing Address - Phone:404-518-3524
Mailing Address - Fax:
Practice Address - Street 1:317 W HILL ST STE 204A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-4367
Practice Address - Country:US
Practice Address - Phone:404-518-3524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010696101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor