Provider Demographics
NPI:1962779488
Name:EDWARDS, JAMIE LYNN (BS)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LIBERTY LN
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2135
Mailing Address - Country:US
Mailing Address - Phone:937-724-2400
Mailing Address - Fax:
Practice Address - Street 1:700 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2135
Practice Address - Country:US
Practice Address - Phone:937-247-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1962779488Medicaid