Healthcare Provider Details

I. General information

NPI: 1679000921
Provider Name (Legal Business Name): JEFFERSON PARK MINISTRIES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 05/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 WEST GRAND ST
ELIZABETH NJ
07202
US

IV. Provider business mailing address

70 WEST GRAND ST
ELIZABETH NJ
07202
US

V. Phone/Fax

Practice location:
  • Phone: 908-469-9508
  • Fax: 908-469-9509
Mailing address:
  • Phone: 908-469-9508
  • Fax: 908-469-9509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: WOODY K PHILIPPE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 908-469-9508