Provider Demographics
NPI:1316838931
Name:MAGNOLIA THERAPY LLC
Entity type:Organization
Organization Name:MAGNOLIA THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JADICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-888-1904
Mailing Address - Street 1:8405 KIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:AL
Mailing Address - Zip Code:36544-4546
Mailing Address - Country:US
Mailing Address - Phone:251-455-2306
Mailing Address - Fax:
Practice Address - Street 1:8405 KIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:AL
Practice Address - Zip Code:36544-4546
Practice Address - Country:US
Practice Address - Phone:251-455-2306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty