Provider Demographics
NPI:1306287073
Name:EADIE, JENMARIE CHRISTINE (LCSW)
Entity type:Individual
Prefix:
First Name:JENMARIE
Middle Name:CHRISTINE
Last Name:EADIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 N MOUNTAIN AVE STE 200V
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4166
Mailing Address - Country:US
Mailing Address - Phone:909-232-2935
Mailing Address - Fax:
Practice Address - Street 1:876 N MOUNTAIN AVE STE 200V
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4166
Practice Address - Country:US
Practice Address - Phone:909-232-2935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA666341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1946482Medicaid