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General NPI Number Information
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NPI Number | 1255744371
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Entity Type | Organization
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Legal Business Name | JEREMIAH COMMUNITY OUTREACH SERVICES, INC
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Dates
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Enumeration Date | 06/05/2014
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Last Update Date | 06/05/2014
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Provider Practice Location Address
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Address Line | 935 175TH ST SUITE 302
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City | HOMEWOOD
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State | IL
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Zip | 60430-2049
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Country | US
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Telephone | 708-914-4248
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Fax | 708-991-2975
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Provider Business Mailing Address
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Address Line | 935 175TH ST SUITE 302
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City | HOMEWOOD
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State | IL
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Zip | 60430-2049
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Country | US
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Telephone | 708-914-4248
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Fax | 708-991-2975
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. SHIRLEY ANN GOLLADAY
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Credential | CADC
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Telephone | 708-914-4248
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | A52410001A
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License Number State | IL
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