Healthcare Provider Details

I. General information

NPI: 1306287073
Provider Name (Legal Business Name): JENMARIE CHRISTINE EADIE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

876 N MOUNTAIN AVE STE 200V
UPLAND CA
91786-4166
US

IV. Provider business mailing address

876 N MOUNTAIN AVE STE 200V
UPLAND CA
91786-4166
US

V. Phone/Fax

Practice location:
  • Phone: 909-232-2935
  • Fax:
Mailing address:
  • Phone: 909-232-2935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number66634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: