Basic Information
| Provider Information | |||||||||
| NPI: | 1104098987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADDOX | ||||||||
| FirstName: | JEANETTA | ||||||||
| MiddleName: | RENA | ||||||||
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| Credential: | M.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1316 SOMERVILLE RD SE STE 1 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356014309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562607361 | ||||||||
| FaxNumber: | 2563556092 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356115318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562323661 | ||||||||
| FaxNumber: | 2563556092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 51547790 | 01 | BCBS | OTHER |