Healthcare Provider Details

I. General information

NPI: 1013186568
Provider Name (Legal Business Name): S E ILLINOIS COUNSELING CTRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 N BASIN RD
FAIRFIELD IL
62837-9639
US

IV. Provider business mailing address

PO BOX M 504 MICAH DRIVE
OLNEY IL
62450-0913
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-2125
  • Fax: 618-842-2126
Mailing address:
  • Phone: 618-395-4306
  • Fax: 618-395-4507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GLENN JACKSON
Title or Position: EXECUTIVE DIRECTOR
Credential: M. DIV., LSW, LCPC
Phone: 618-395-4309