Provider Demographics
NPI:1982265294
Name:CROCKETT, JOANNA MANN
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:MANN
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 WHEELER RD STE 365
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6549
Mailing Address - Country:US
Mailing Address - Phone:706-432-6866
Mailing Address - Fax:706-432-8775
Practice Address - Street 1:1202 TOWN PARK LN STE 300
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3477
Practice Address - Country:US
Practice Address - Phone:706-210-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007932101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional