Provider Demographics
NPI:1548538572
Name:COLEMAN, JAY C JR (ALC)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:C
Last Name:COLEMAN
Suffix:JR
Gender:M
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 EDINBURGH DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2105
Mailing Address - Country:US
Mailing Address - Phone:334-294-8717
Mailing Address - Fax:
Practice Address - Street 1:2225 EDINBURGH DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2105
Practice Address - Country:US
Practice Address - Phone:334-294-8717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
ALC3640A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)