Provider Demographics
NPI:1366210205
Name:JEREMIAH 29:11 COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:JEREMIAH 29:11 COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:206-291-5998
Mailing Address - Street 1:1 N MACDONALD STE B19
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-7339
Mailing Address - Country:US
Mailing Address - Phone:206-291-5998
Mailing Address - Fax:
Practice Address - Street 1:1 N MACDONALD STE B19
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-7339
Practice Address - Country:US
Practice Address - Phone:206-291-5998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty