MEDICARE: THE VILLAGE CONSULTANT, 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	251S00000X	Community/Behavioral Health Agency	1322	AL

General Provider Information

NPI Number	:	1871800490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE VILLAGE CONSULTANT, LLC

Provider Business Mailing Address
First Line	:	350 CANYON PARK DR
Second Line	:
City	:	PELHAM
State	:	AL
Zip	:	35124-4819
Country	:	US
Telephone Number	:	205-603-1411
Fax Number	:

Provider Business Practice Location Address
First Line	:	5780 HERITAGE PARK DR
Second Line	:
City	:	MC CALLA
State	:	AL
Zip	:	35111-3490
Country	:	US
Telephone Number	:	205-603-1411
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MELISSA FAYE JACKSON
Credential	:	PH.D.
Telephone Number	:	205-603-1411

Provider Enumeration Date	:	09/02/2010
Last Update Date	:	09/02/2010

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