Organization
S E ILLINOIS COUNSELING CTRS
Active
Other names
WAYNE FAMILY COUNSELING CTR
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GLENN JACKSON M. DIV., LSW, LCPC (EXECUTIVE DIRECTOR)
(618) 395-4309
Entity
Organization
Contact information
Practice address
407 N BASIN RD, FAIRFIELD, IL 62837-9639
(618) 842-2125
(618) 842-2126
Mailing address
PO BOX M, 504 MICAH DRIVE, OLNEY, IL 62450-0913
(618) 395-4306
(618) 395-4507
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
251S00000X
Community/Behavioral Health Agency
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
Other
Enumeration date
02/28/2008
Last updated
05/05/2016
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