Healthcare Provider Details

I. General information

NPI: 1093013005
Provider Name (Legal Business Name): JENNIFER POORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WINNSTEAD DR
LEESBURG GA
31763-5376
US

IV. Provider business mailing address

PO BOX 71461
ALBANY GA
31708-1461
US

V. Phone/Fax

Practice location:
  • Phone: 229-869-6735
  • Fax:
Mailing address:
  • Phone: 229-869-6735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11369
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009959
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: