Healthcare Provider Details

I. General information

NPI: 1063996619
Provider Name (Legal Business Name): JONATHON MICHAEL PRYOR LPC, LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6692 TANGLEWOOD DR
BLACKSHEAR GA
31516-7530
US

IV. Provider business mailing address

PO BOX 1884
WAYCROSS GA
31502-1884
US

V. Phone/Fax

Practice location:
  • Phone: 912-590-2981
  • Fax:
Mailing address:
  • Phone: 912-590-2981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16923
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC010482
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: