MEDICARE: EMPOWERMENT CLINICAL & CONSULTING SERVICES OF FREDERICKSBURG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	829-05-001	VA
2	101Y00000X	Counselor	829	VA
3	101YM0800X	Mental Health Counselor	829-05-001	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194954008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPOWERMENT CLINICAL & CONSULTING SERVICES OF FREDERICKSBURG

Provider Business Mailing Address
First Line	:	830 SOUTHLAKE BLVD STE C
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23236-3935
Country	:	US
Telephone Number	:	804-378-7710
Fax Number	:

Provider Business Practice Location Address
First Line	:	307 LAFAYETTE BLVD
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-6066
Country	:	US
Telephone Number	:	540-903-3487
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RUDI JACKSON
Credential	:
Telephone Number	:	804-378-7710

Provider Enumeration Date	:	07/13/2009
Last Update Date	:	04/08/2011

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