Provider Demographics
NPI:1467597872
Name:FAMILY COUNSELING CENTER OF MISSOURI INC
Entity Type:Organization
Organization Name:FAMILY COUNSELING CENTER OF MISSOURI INC
Other - Org Name:JEFFERSON CITY OUTPATIENT CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TACKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-443-2204
Mailing Address - Street 1:117 N GARTH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4103
Mailing Address - Country:US
Mailing Address - Phone:573-443-2204
Mailing Address - Fax:573-875-6607
Practice Address - Street 1:204 METRO DR
Practice Address - Street 2:SUITE B
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-4408
Practice Address - Country:US
Practice Address - Phone:573-634-4591
Practice Address - Fax:573-634-4792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1649269622OtherFCCMO BILLING NPI NUMBER