Healthcare Provider Details

I. General information

NPI: 1881828788
Provider Name (Legal Business Name): JEFFERSON COUNTY COMPREHENSIVE SVC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16342 N IL HWY 37
MT VERNON IL
62864
US

IV. Provider business mailing address

PO BOX 428
MOUNT VERNON IL
62864-0054
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-1994
  • Fax: 618-242-6392
Mailing address:
  • Phone: 618-242-1994
  • Fax: 618-242-6392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number002250002
License Number StateIL

VIII. Authorized Official

Name: MR. DANIEL P BOEHMER
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, LCPC, QMHP
Phone: 618-242-1994