Healthcare Provider Details

I. General information

NPI: 1386289031
Provider Name (Legal Business Name): HAVEN ADOLESCENT COMMUNITY RESPITE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 ROOSEVELT AVE
JERSEY CITY NJ
07304-1207
US

IV. Provider business mailing address

53 DUNCAN AVE APT 21
JERSEY CITY NJ
07304-2150
US

V. Phone/Fax

Practice location:
  • Phone: 201-433-3891
  • Fax:
Mailing address:
  • Phone: 201-433-3891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State

VIII. Authorized Official

Name: JESSICA TAUBE
Title or Position: OPERATIONAL DIRECTOR
Credential: LSW
Phone: 201-433-3891