Healthcare Provider Details

I. General information

NPI: 1407937923
Provider Name (Legal Business Name): JAMESETTA EDWARDS BFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH & ROOSEVELT
HINES IL
60141
US

IV. Provider business mailing address

1204 TRYON RD
MICHIGAN CITY IN
46360-2260
US

V. Phone/Fax

Practice location:
  • Phone: 707-282-8387
  • Fax: 708-202-7013
Mailing address:
  • Phone: 708-228-3601
  • Fax: 219-875-3699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: