=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245418128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2008
-----------------------------------------------------
Last Update Date | 07/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 W JOURDAN ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62448-1062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-783-8615
-----------------------------------------------------
Fax | 618-783-4174
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX M
-----------------------------------------------------
City | OLNEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62450-0913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-395-4306
-----------------------------------------------------
Fax | 618-395-4507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. GLENN JACKSON
-----------------------------------------------------
Credential | M. DIV., LSW, LCPC
-----------------------------------------------------
Telephone | 618-395-4309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------