Healthcare Provider Details

I. General information

NPI: 1013483023
Provider Name (Legal Business Name): KSA YOUTH FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10905 FORT WASHINGTON RD STE 105
FORT WASHINGTON MD
20744-5844
US

IV. Provider business mailing address

10905 FORT WASHINGTON RD STE 105
FORT WASHINGTON MD
20744-5844
US

V. Phone/Fax

Practice location:
  • Phone: 240-766-4194
  • Fax: 301-485-0363
Mailing address:
  • Phone: 240-766-4194
  • Fax: 301-485-0363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATRINA ANN WILKINS-JACKSON
Title or Position: PRESIDENT & CEO
Credential: PHD
Phone: 240-766-4194