MEDICARE: JAMAICAN MOON GROUP, LLC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor		TX

General Provider Information

NPI Number	:	1194974642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAMAICAN MOON GROUP, LLC

Provider Business Mailing Address
First Line	:	930 W MAIN ST
Second Line	:
City	:	LEWISVILLE
State	:	TX
Zip	:	75067-3644
Country	:	US
Telephone Number	:	214-222-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 N WESTMORELAND RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75211-2444
Country	:	US
Telephone Number	:	214-330-4111
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BOB SCOUTEN
Credential	:
Telephone Number	:	214-222-2100

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	09/09/2008

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