Healthcare Provider Details

I. General information

NPI: 1205347747
Provider Name (Legal Business Name): FAIRWAY COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 2376
JENA LA
71342-2376
US

IV. Provider business mailing address

PO BOX 2376
JENA LA
71342-2376
US

V. Phone/Fax

Practice location:
  • Phone: 318-992-2263
  • Fax: 318-992-2267
Mailing address:
  • Phone: 318-992-2263
  • Fax: 318-992-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JASMINE FURLOW
Title or Position: MENTAL HEALTH SPECIALIST
Credential:
Phone: 318-992-2263