Provider Demographics
NPI:1194954008
Name:EMPOWERMENT CLINICAL & CONSULTING SERVICES OF FREDERICKSBURG
Entity type:Organization
Organization Name:EMPOWERMENT CLINICAL & CONSULTING SERVICES OF FREDERICKSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUDI
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-378-7710
Mailing Address - Street 1:830 SOUTHLAKE BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236-3935
Mailing Address - Country:US
Mailing Address - Phone:804-378-7710
Mailing Address - Fax:
Practice Address - Street 1:307 LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-6066
Practice Address - Country:US
Practice Address - Phone:540-903-3487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA829101Y00000X
VA829-05-001101YM0800X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194954008Medicaid