=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578910808
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDEN COUNSELING CENTERS LLC MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2016
-----------------------------------------------------
Last Update Date | 05/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8794 BIG BEAR AVENUE
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43065-9113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-398-3470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8794 BIG BEAR AVENUE
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43065-9113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-398-3470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. WILLIAM EARL JENNINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-398-3470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084B0040X
-----------------------------------------------------
Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
-----------------------------------------------------
License Number | 34010652
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------