Healthcare Provider Details

I. General information

NPI: 1174976757
Provider Name (Legal Business Name): NORTH IOWA JUVENILE DETENTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 W DUNKERTON RD
WATERLOO IA
50703-9648
US

IV. Provider business mailing address

1440 W DUNKERTON RD
WATERLOO IA
50703-9648
US

V. Phone/Fax

Practice location:
  • Phone: 319-291-2455
  • Fax: 319-291-2464
Mailing address:
  • Phone: 319-291-2455
  • Fax: 319-291-2464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: AMBER LACINA
Title or Position: MEDICAL DIRECTOR
Credential: BSN, RN, MSN, APMHNP
Phone: 319-291-2455