Healthcare Provider Details

I. General information

NPI: 1821117391
Provider Name (Legal Business Name): DCCCA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E MADISON ST
PITTSBURG KS
66762-6023
US

IV. Provider business mailing address

3312 CLINTON PKWY
LAWRENCE KS
66047-3624
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-6129
  • Fax: 620-231-0447
Mailing address:
  • Phone: 785-841-4138
  • Fax: 785-841-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number052
License Number StateKS

VIII. Authorized Official

Name: KERYE J JACKSON
Title or Position: CFO
Credential: CPA, CMA
Phone: 785-841-4138