Healthcare Provider Details

I. General information

NPI: 1689790495
Provider Name (Legal Business Name): SOUTHEASTERN PSYCHOLOGICAL AND COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 HONEYSUCKLE RD SUITE 14
DOTHAN AL
36305-1157
US

IV. Provider business mailing address

256 HONEYSUCKLE RD SUITE 14
DOTHAN AL
36305-1157
US

V. Phone/Fax

Practice location:
  • Phone: 334-794-5467
  • Fax: 334-677-1051
Mailing address:
  • Phone: 334-794-5467
  • Fax: 334-677-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1377
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number325
License Number StateAL

VIII. Authorized Official

Name: J. WALTER JACOBS
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 334-794-5467