Provider Demographics
NPI:1013210178
Name:YOUTH AND FAMILY DYNAMICS MENTAL HEALTH SUPPORT, LLC
Entity Type:Organization
Organization Name:YOUTH AND FAMILY DYNAMICS MENTAL HEALTH SUPPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:BS
Authorized Official - Phone:804-477-3065
Mailing Address - Street 1:1733 FIRST COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-6892
Mailing Address - Country:US
Mailing Address - Phone:804-501-9440
Mailing Address - Fax:804-222-8122
Practice Address - Street 1:5741 S LABURNUM AVE
Practice Address - Street 2:SUITE #111
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23231-4431
Practice Address - Country:US
Practice Address - Phone:804-477-3065
Practice Address - Fax:804-477-3092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1162251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health