Provider Demographics
NPI:1326407453
Name:SOUTHERN BRIDGE COUNSELING, LLC
Entity Type:Organization
Organization Name:SOUTHERN BRIDGE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-689-5190
Mailing Address - Street 1:100 SHOSHONE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047
Mailing Address - Country:US
Mailing Address - Phone:910-689-5190
Mailing Address - Fax:
Practice Address - Street 1:100 SHOSHONE CIRCLE
Practice Address - Street 2:
Practice Address - City:KATHLEEN
Practice Address - State:GA
Practice Address - Zip Code:31047
Practice Address - Country:US
Practice Address - Phone:910-689-5190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health