Healthcare Provider Details

I. General information

NPI: 1184922189
Provider Name (Legal Business Name): JEANIE DALE MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1353 N MOUNT AUBURN RD SUITE C
CAPE GIRARDEAU MO
63701-1727
US

IV. Provider business mailing address

2909 INDEPENDENCE ST
CAPE GIRARDEAU MO
63703-5044
US

V. Phone/Fax

Practice location:
  • Phone: 573-803-1402
  • Fax:
Mailing address:
  • Phone: 573-803-1402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002485
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: