Healthcare Provider Details

I. General information

NPI: 1386996643
Provider Name (Legal Business Name): JUNETTA WATSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 TIFTON ELDORADO RD
TIFTON GA
31794-9497
US

IV. Provider business mailing address

3120 N OAK ST
VALDOSTA GA
31602-1003
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-2300
  • Fax: 229-671-6774
Mailing address:
  • Phone: 229-671-6100
  • Fax: 229-671-6774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number006968
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: