=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316009145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEWISH FAMILY & CHILDREN'S SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 07/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5701 W TALAVI BLVD STE 180
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85306-1888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-486-8202
-----------------------------------------------------
Fax | 623-486-2739
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4747 N 7TH ST STE 100
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85014-3654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-279-7655
-----------------------------------------------------
Fax | 602-253-8891
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | DR. LORRIE HENDERSON
-----------------------------------------------------
Credential | PHD, MBA, LCSW
-----------------------------------------------------
Telephone | 602-279-7655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------