MEDICARE: MS. LAVONNA WINFREDA OWENS-JACKSON LPC, CCM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC008416	GA

General Provider Information

NPI Number	:	1891439337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAVONNA WINFREDA OWENS-JACKSON LPC, CCM

Provider Business Mailing Address
First Line	:	3040 LAKESIDE CIR
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30016-8892
Country	:	US
Telephone Number	:	678-478-5860
Fax Number	:

Provider Business Practice Location Address
First Line	:	1192 ROCKBRIDGE RD STE A
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-2923
Country	:	US
Telephone Number	:	770-925-2010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2022
Last Update Date	:	04/21/2022

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