| NPI | 1427292622 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER L JACKSON Senior Director Provider Enrollment 877-892-9815 |
| Organization Subpart ? | No |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry |
| Additional Taxonomies | 103T00000X Psychologist |
| 103TC0700X Psychologist, Clinical | |
| 104100000X Social Worker | |
| 1041C0700X Social Worker, Clinical | |
| 106H00000X Marriage & Family Therapist | |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2009-05-01 |
| Last Update Date | 2022-01-25 |