Healthcare Provider Details

I. General information

NPI: 1093977613
Provider Name (Legal Business Name): MAUREEN DE JONGE RN, MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 OBRIEN DR
KATHLEEN GA
31047-5337
US

IV. Provider business mailing address

193 HARNER RD
KATHLEEN GA
31047-2010
US

V. Phone/Fax

Practice location:
  • Phone: 478-988-3188
  • Fax: 478-988-3188
Mailing address:
  • Phone: 478-213-0256
  • Fax: 478-213-0256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC5955
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: