Provider Demographics
NPI:1306590328
Name:EDGECARE 360 LLC
Entity type:Organization
Organization Name:EDGECARE 360 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:910-212-2496
Mailing Address - Street 1:225 FRANKLIN FARMS CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-3363
Mailing Address - Country:US
Mailing Address - Phone:678-561-5066
Mailing Address - Fax:
Practice Address - Street 1:2470 WINDY HILL RD SE STE 300
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8621
Practice Address - Country:US
Practice Address - Phone:770-933-5328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-08
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health