MEDICARE: LIFE SOURCE COUNSELING CENTER, INC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1801565999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE SOURCE COUNSELING CENTER, INC

Provider Business Mailing Address
First Line	:	3516 PLANK RD STE 5C
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22407-6861
Country	:	US
Telephone Number	:	301-523-3642
Fax Number	:	540-301-2403

Provider Business Practice Location Address
First Line	:	3516 PLANK RD STE 5C
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22407-6861
Country	:	US
Telephone Number	:	540-786-3049
Fax Number	:	540-301-2403

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTAL ROCHELLE JONES
Credential	:	LCSW
Telephone Number	:	301-523-3642

Provider Enumeration Date	:	09/10/2021
Last Update Date	:	09/10/2021

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