Healthcare Provider Details

I. General information

NPI: 1538807748
Provider Name (Legal Business Name): NORTH IOWA JUVENILE DETENTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 LOGAN AVE
WATERLOO IA
50703-1947
US

IV. Provider business mailing address

1440 W DUNKERTON RD
WATERLOO IA
50703-9648
US

V. Phone/Fax

Practice location:
  • Phone: 319-888-7255
  • Fax:
Mailing address:
  • Phone: 319-291-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ERICA DEGROOT
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 319-888-7255