MEDICARE: DCCCA, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency
3	253J00000X	Foster Care Agency

General Provider Information

NPI Number	:	1558632299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DCCCA, INC

Provider Business Mailing Address
First Line	:	3312 CLINTON PKWY
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66047-3624
Country	:	US
Telephone Number	:	785-841-4138
Fax Number	:	785-841-5777

Provider Business Practice Location Address
First Line	:	3517 LAKE RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-5168
Country	:	US
Telephone Number	:	785-841-4138
Fax Number	:	785-841-5777

Authorized Official
Title or Position	:	CFO
Name	:	KERYE J. JACKSON
Credential	:	CPA, CMA
Telephone Number	:	785-841-4138

Provider Enumeration Date	:	01/25/2012
Last Update Date	:	05/29/2020

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Directions to “DCCCA, INC ” Practice Location

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