MEDICARE: MR. JEFFERY BRYANT EADS LPC

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	101YM0800X	Mental Health Counselor	4697	NC

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	:	1366595415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFERY BRYANT EADS LPC

Provider Business Mailing Address
First Line	:	218 ORCHARD ST
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-2812
Country	:	US
Telephone Number	:	336-786-2336
Fax Number	:

Provider Business Practice Location Address
First Line	:	351 RIVERSIDE DR
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-3850
Country	:	US
Telephone Number	:	336-786-7079
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2007
Last Update Date	:	07/08/2007

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