SOUTH EASTERN ILLINOIS COUNSELING CENTER INC

Provider Demographics

• NPI: 1336137199
• Name: SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
• Entity Type: Organization
• Organization Name: SOUTH EASTERN ILLINOIS COUNSELING CENTER INC
• Authorized Official - Title/Position: EXECUTIVE DIRECTOR
• Authorized Official - Prefix: MR
• Authorized Official - First Name: GLENN
• Authorized Official - Last Name: JACKSON
• Authorized Official - Credentials: MDIV, LSW, LCPC
• Authorized Official - Phone: 618-395-4309
• Mailing Address - Street 1: PO BOX M
• Mailing Address - Street 2: 504 MICAH DRIVE
• Mailing Address - City: OLNEY
• Mailing Address - State: IL
• Mailing Address - Zip Code: 62450-0913
• Mailing Address - Country: US
• Mailing Address - Phone: 618-395-4306
• Mailing Address - Fax: 618-395-4507
• Practice Address - Street 1: 504 MICAH DRIVE
• Practice Address - Street 2: DRAWER M
• Practice Address - City: OLNEY
• Practice Address - State: IL
• Practice Address - Zip Code: 62450
• Practice Address - Country: US
• Practice Address - Phone: 618-395-4306
• Practice Address - Fax: 618-395-4507
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-10-06
• Last Update Date: 2016-05-05

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	101YA0400X	Behavioral Health & Social Service Providers	Counselor	Addiction (Substance Use Disorder)	Group - Multi-Specialty
No	101Y00000X	Behavioral Health & Social Service Providers	Counselor		Group - Multi-Specialty
No	101YM0800X	Behavioral Health & Social Service Providers	Counselor	Mental Health	Group - Multi-Specialty
No	101YP2500X	Behavioral Health & Social Service Providers	Counselor	Professional	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IL	036037359	Medicaid
IL	343700207	Medicaid
IL	036072942	Medicaid
IL	=========022	Medicaid
IL	=========034	Medicaid
IL	=========035	Medicaid
IL	=========036	Medicaid
IL	036037359	Medicaid
IL	=========004	Medicaid
IL	=========023	Medicaid
IL	343700207	Medicaid
IL	=========003	Medicaid
IL	=========009	Medicaid
IL	=========008	Medicaid
IL	=========017	Medicaid
IL	=========020	Medicaid
IL	=========037	Medicaid
IL	=========009	Medicaid