MEDICARE: MR. JERRY VINCENT THOMAS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	4299	GA

General Provider Information

NPI Number	:	1730232521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY VINCENT THOMAS LPC

Provider Business Mailing Address
First Line	:	3047 HUDSON CT
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-1115
Country	:	US
Telephone Number	:	404-587-8707
Fax Number	:	404-633-4403

Provider Business Practice Location Address
First Line	:	4001 PRESIDENTIAL PKWY
Second Line	:	700
City	:	ATLANTA
State	:	GA
Zip	:	30340-3719
Country	:	US
Telephone Number	:	404-587-8707
Fax Number	:	404-633-4403

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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