=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225271687
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER AUSTIN MAIN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2009
-----------------------------------------------------
Last Update Date | 08/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 RICKY D BRITT SR BLVD STE 4
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38655-9103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-417-2824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 RICKY D BRITT SR BLVD STE 4
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38655-9103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-417-2824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | APC002193
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2046
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------