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General NPI Number Information
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NPI Number | 1306232632
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Entity Type | Organization
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Legal Business Name | JACKSON COUNTY YOUTH CENTER
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Dates
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Enumeration Date | 04/14/2015
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Last Update Date | 04/14/2015
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Provider Practice Location Address
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Address Line | 930 FLEMING AVE
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City | JACKSON
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State | MI
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Zip | 49202-2534
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Country | US
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Telephone | 517-788-4460
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Fax | 517-788-4661
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Provider Business Mailing Address
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Address Line | 930 FLEMING AVE
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City | JACKSON
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State | MI
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Zip | 49202-2534
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Country | US
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Telephone | 517-788-4460
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Fax | 517-788-4661
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. GEREMY C BURNS
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Credential | MA
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Telephone | 517-768-2778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | CO380201204
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License Number State | MI
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