=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083171896
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM COTTRELL-JACKSON LPC, NCC
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2019
-----------------------------------------------------
Last Update Date | 07/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 888 HORIZON BLVD APT 314
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-1136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-805-8468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 888 HORIZON BLVD APT 314
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-1136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-805-8468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401224328
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC012968
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------