MEDICARE: JENNIFER HAINES-PRUITT 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	101YM0800X	Mental Health Counselor	LPC007776	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962948687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER HAINES-PRUITT LPC

Provider Business Mailing Address
First Line	:	5463 STONEYBROOK CT SE
Second Line	:
City	:	MABLETON
State	:	GA
Zip	:	30126-5625
Country	:	US
Telephone Number	:	937-681-5630
Fax Number	:

Provider Business Practice Location Address
First Line	:	561 THORNTON RD STE R
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-1558
Country	:	US
Telephone Number	:	678-653-6314
Fax Number	:

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

Provider Enumeration Date	:	01/19/2017
Last Update Date	:	09/14/2018

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