Healthcare Provider Details

I. General information

NPI: 1235566126
Provider Name (Legal Business Name): JACK LENFORD ABERNATHY JR. MS, NCC, CCMHC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 11/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CIRCLE 75 PKWY SE SUITE 1435
ATLANTA GA
30339-3905
US

IV. Provider business mailing address

900 CIRCLE 75 PKWY SE SUITE 1435
ATLANTA GA
30339-3905
US

V. Phone/Fax

Practice location:
  • Phone: 404-895-0990
  • Fax: 770-485-5906
Mailing address:
  • Phone: 404-895-0990
  • Fax: 770-485-5906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC007969
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007969
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: