Healthcare Provider Details

I. General information

NPI: 1700380649
Provider Name (Legal Business Name): JITHIN JOSEPH GEORGE LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 SW 3RD STREET
BOCA RATON FL
33432
US

IV. Provider business mailing address

9995 N MILITARY TRAIL
PALM BEACH GARDENS FL
33410
US

V. Phone/Fax

Practice location:
  • Phone: 844-848-6777
  • Fax:
Mailing address:
  • Phone: 561-775-9579
  • Fax: 772-220-9894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: