Provider Demographics
NPI:1316765480
Name:BLU JAAE COUNSELING SERVICES
Entity type:Organization
Organization Name:BLU JAAE COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:EBONEE
Authorized Official - Middle Name:PERTRICE
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CRC, LCMHC, ALC
Authorized Official - Phone:252-518-5223
Mailing Address - Street 1:615 SAINT GEORGE SQUARE CT
Mailing Address - Street 2:STE 300
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1368
Mailing Address - Country:US
Mailing Address - Phone:252-518-5223
Mailing Address - Fax:
Practice Address - Street 1:615 SAINT GEORGE SQUARE CT
Practice Address - Street 2:STE 300
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1368
Practice Address - Country:US
Practice Address - Phone:252-518-5223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty