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General NPI Number Information
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NPI Number | 1053682724
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Entity Type | Organization
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Legal Business Name | CENTER FOR FAMILY LIFE EXTENSION, INC.
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Dates
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Enumeration Date | 01/26/2012
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Last Update Date | 03/22/2021
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Provider Practice Location Address
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Address Line | 1980 HIGHWAY 80 W
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City | JACKSON
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State | MS
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Zip | 39204-2303
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Country | US
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Telephone | 601-259-5745
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Fax | 601-871-8223
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Provider Business Mailing Address
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Address Line | 1980 HIGHWAY 80 W
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City | JACKSON
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State | MS
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Zip | 39204-2303
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Country | US
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Telephone | 601-259-5745
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ELMINA JOHNSON
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Credential |
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Telephone | 601-259-5745
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | CYS-CFL-TGH-01
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | CYS-CFL-TGH-01
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License Number State | MS
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