MEDICARE: BRIDGING SEVENTEEN COUNSELING CENTER, LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	LPC006595	GA
2	261QM0850X	Adult Mental Health Clinic/Center	LPC006595	GA
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center	LPC006595	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	I534865	OTHER	GA	AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	671155	OTHER	GA	BCBS OF GA

General Provider Information

NPI Number	:	1518487404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGING SEVENTEEN COUNSELING CENTER, LLC

Provider Business Mailing Address
First Line	:	4157 ELDERS DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-9145
Country	:	US
Telephone Number	:	706-496-1010
Fax Number	:	877-496-4637

Provider Business Practice Location Address
First Line	:	3108 PEACH ORCHARD RD #6419
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-3090
Country	:	US
Telephone Number	:	706-496-1010
Fax Number	:	877-496-4637

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. TERRI VERNESE JENKINS
Credential	:	ED.D, LPC, NCC, ACS
Telephone Number	:	706-496-1010

Provider Enumeration Date	:	06/22/2017
Last Update Date	:	06/22/2017

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