Provider Demographics
NPI:1073782579
Name:COUNTY OF JASPER
Entity Type:Organization
Organization Name:COUNTY OF JASPER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:618-783-4154
Mailing Address - Street 1:106 EAST EDWARDS
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448-1736
Mailing Address - Country:US
Mailing Address - Phone:618-783-4154
Mailing Address - Fax:618-783-2339
Practice Address - Street 1:106 EAST EDWARDS
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IL
Practice Address - Zip Code:62448-1736
Practice Address - Country:US
Practice Address - Phone:618-783-4154
Practice Address - Fax:618-783-2339
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF JASPER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-28
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04082251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health