Provider Demographics
NPI:1689790495
Name:SOUTHEASTERN PSYCHOLOGICAL AND COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN PSYCHOLOGICAL AND COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:334-794-5467
Mailing Address - Street 1:256 HONEYSUCKLE RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1157
Mailing Address - Country:US
Mailing Address - Phone:334-794-5467
Mailing Address - Fax:334-677-1051
Practice Address - Street 1:256 HONEYSUCKLE RD
Practice Address - Street 2:SUITE 14
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1157
Practice Address - Country:US
Practice Address - Phone:334-794-5467
Practice Address - Fax:334-677-1051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1377101YP2500X
AL325103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty