=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922518125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LJ INDEPENDENT SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2017
-----------------------------------------------------
Last Update Date | 10/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 MEMORIAL HWY APT 14H
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10801-8326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-504-7948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 MEMORIAL HWY APT 14H
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10801-8326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-504-7948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. LORETTA FRANCES JACKSON
-----------------------------------------------------
Credential | MSED
-----------------------------------------------------
Telephone | 917-594-7948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 109522413
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------