Provider Demographics
NPI:1003180746
Name:SUCCESSFUL JOURNEYS DAY PROGRAM, LLC
Entity Type:Organization
Organization Name:SUCCESSFUL JOURNEYS DAY PROGRAM, LLC
Other - Org Name:SUCCESSFUL JOURNEYS DAY PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:SEKOU
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPA, CPM
Authorized Official - Phone:623-478-9400
Mailing Address - Street 1:9950 W VAN BUREN ST
Mailing Address - Street 2:B135
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-5322
Mailing Address - Country:US
Mailing Address - Phone:623-478-9400
Mailing Address - Fax:623-478-9500
Practice Address - Street 1:9950 W VAN BUREN ST
Practice Address - Street 2:B135
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-5322
Practice Address - Country:US
Practice Address - Phone:623-478-9400
Practice Address - Fax:623-478-9500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3967261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)