Basic Information
| Provider Information | |||||||||
| NPI: | 1962779488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | B.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 700 LIBERTY LN | ||||||||
| Address2: | |||||||||
| City: | WEST CARROLLTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454492135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377242400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 LIBERTY LN | ||||||||
| Address2: | |||||||||
| City: | WEST CARROLLTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454492135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372472400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2011 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1962779488 | 05 | IL | MEDICAID |