Healthcare Provider Details

I. General information

NPI: 1740546225
Provider Name (Legal Business Name): JOY JENNIFER FORTNER-EDRIS LPC, LMFT, CACP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 RILEY SMITH DRIVE
GREENVILLE SC
29615
US

IV. Provider business mailing address

185 RILEY SMITH DRIVE
GREENVILLE SC
29615
US

V. Phone/Fax

Practice location:
  • Phone: 864-297-5101
  • Fax: 864-297-5423
Mailing address:
  • Phone: 864-297-5101
  • Fax: 864-297-5423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5473
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5267
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5482
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4599
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: