Healthcare Provider Details

I. General information

NPI: 1366210205
Provider Name (Legal Business Name): JEREMIAH 29:11 COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2023
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 N MACDONALD STE B19
MESA AZ
85201-7339
US

IV. Provider business mailing address

1 N MACDONALD STE B19
MESA AZ
85201-7339
US

V. Phone/Fax

Practice location:
  • Phone: 206-291-5998
  • Fax:
Mailing address:
  • Phone: 206-291-5998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. GRADY SMITH
Title or Position: NP/OWNER
Credential: NP
Phone: 206-291-5998