1376701193 NPI number — THE HOUSE OF JUDE CHILDREN SERVICES

Table of content: (NPI 1376701193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376701193 NPI number — THE HOUSE OF JUDE CHILDREN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE HOUSE OF JUDE CHILDREN SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE HOUSE OF JUDE BEHAVIORAL HEALTH SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376701193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 5004
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLE RIVER
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-705-1331
Provider Business Mailing Address Fax Number:
410-938-2237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 E. 25TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-705-1331
Provider Business Practice Location Address Fax Number:
410-938-2237
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
AUGUSTSON
Authorized Official First Name:
EDITH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-705-1331

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: NCC-93405 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: LC-2284 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 414755300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 411699201 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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