Provider Demographics
NPI:1104002963
Name:SOUTH JESERY BEHAVORIAL RESOURCE
Entity Type:Organization
Organization Name:SOUTH JESERY BEHAVORIAL RESOURCE
Other - Org Name:COSTAR
Other - Org Type:Other Name
Authorized Official - Title/Position:MENTAL HEALTH AIDE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:KALISE
Authorized Official - Last Name:CRAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-541-1700
Mailing Address - Street 1:530 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08102-1252
Mailing Address - Country:US
Mailing Address - Phone:856-541-1700
Mailing Address - Fax:856-225-1373
Practice Address - Street 1:530 COOPER ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08102-1252
Practice Address - Country:US
Practice Address - Phone:856-541-1700
Practice Address - Fax:856-225-1373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health