1790833424 NPI number — MJ COUNSELING AND CASE MANAGEMENT

Table of content: (NPI 1790833424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790833424 NPI number — MJ COUNSELING AND CASE MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MJ COUNSELING AND CASE MANAGEMENT
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:
Provider Other Organization Name Type Code:
6
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:
1790833424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2328 MOUNTAIN VIEW DR
Provider Second Line Business Mailing Address:
BOX 130
Provider Business Mailing Address City Name:
EMMETT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83617-9533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-365-3183
Provider Business Mailing Address Fax Number:
208-365-2307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2328 MOUNTAIN VIEW DR
Provider Second Line Business Practice Location Address:
BOX 130
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-9533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-3183
Provider Business Practice Location Address Fax Number:
208-365-2307
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
LEE ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNERADMINISTRATOR
Authorized Official Telephone Number:
208-365-3183

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , with the licence number:  C148733 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , with the licence number: C148733 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002748300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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