Basic Information
| Provider Information | |||||||||
| NPI: | 1932251758 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ILLINOIS REGIONAL SOCIAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JACKSON COUNTY COMMUNITY MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 604 EAST COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184576703 | ||||||||
| FaxNumber: | 6184578377 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184576703 | ||||||||
| FaxNumber: | 6184578377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 09/15/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FREITAG | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6184576703 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN ILLINOIS REGIONAL SOCIAL SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | A-0243-0001-A | IL | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 002 | 05 | IL | MEDICAID |