Healthcare Provider Details

I. General information

NPI: 1790184661
Provider Name (Legal Business Name): JENNY EDMINSON LCSW, LCASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2014
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WALTER REED DR
GREENSBORO NC
27403-1128
US

IV. Provider business mailing address

700 WALTER REED DR
GREENSBORO NC
27403-1128
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-9800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS21186
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC010418
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: