MEDICARE: CROSSROADS ADDICTION & MENTAL HEALTH SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	901	NE
2	251S00000X	Community/Behavioral Health Agency	569	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003256082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS ADDICTION & MENTAL HEALTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	1000 W 29TH ST
Second Line	:	SUITE 320
City	:	SOUTH SIOUX CITY
State	:	NE
Zip	:	68776-3852
Country	:	US
Telephone Number	:	712-574-4357
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 W 29TH ST
Second Line	:	SUITE 320
City	:	SOUTH SIOUX CITY
State	:	NE
Zip	:	68776-3852
Country	:	US
Telephone Number	:	712-574-4357
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. STEPHANIE ANN JENSEN
Credential	:	PH.D
Telephone Number	:	712-301-4518

Provider Enumeration Date	:	07/05/2013
Last Update Date	:	12/31/2014

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