Healthcare Provider Details

I. General information

NPI: 1366631459
Provider Name (Legal Business Name): JACKIE EADS LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKIE REDMON

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 PARKERS MILL RD
SOMERSET KY
42501-3152
US

IV. Provider business mailing address

130 SOUTHERN SCHOOL RD
SOMERSET KY
42501-3223
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-7348
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: