Provider Demographics
NPI:1093876542
Name:JEWISH FAMILY AND CHILDREN'S SERVICE OF SOUTHERN ARIZONA, INC
Entity Type:Organization
Organization Name:JEWISH FAMILY AND CHILDREN'S SERVICE OF SOUTHERN ARIZONA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-795-0300
Mailing Address - Street 1:4301 EAST 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2005
Mailing Address - Country:US
Mailing Address - Phone:520-795-0300
Mailing Address - Fax:520-795-8206
Practice Address - Street 1:4301 EAST 5TH STREET
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2005
Practice Address - Country:US
Practice Address - Phone:520-795-0300
Practice Address - Fax:520-795-8206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH1600104100000X
AZBH213261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ116865Medicaid
AZ116865Medicaid