Provider Demographics
NPI:1033886908
Name:RENEWED JOURNEY PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:RENEWED JOURNEY PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:520-904-5277
Mailing Address - Street 1:5917 E PIMA ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4387
Mailing Address - Country:US
Mailing Address - Phone:520-904-5277
Mailing Address - Fax:855-718-2713
Practice Address - Street 1:5917 E PIMA ST UNIT 3
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4387
Practice Address - Country:US
Practice Address - Phone:520-904-5277
Practice Address - Fax:520-904-5277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-26
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ195157Medicaid