Healthcare Provider Details

I. General information

NPI: 1336137199
Provider Name (Legal Business Name): SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 MICAH DRIVE DRAWER M
OLNEY IL
62450
US

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
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