Provider Demographics
NPI:1114309721
Name:URBAN INTERVENTIONAL STRATEGIES
Entity Type:Organization
Organization Name:URBAN INTERVENTIONAL STRATEGIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:240-461-3008
Mailing Address - Street 1:15108 DOVEHEART LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3054
Mailing Address - Country:US
Mailing Address - Phone:240-461-3008
Mailing Address - Fax:
Practice Address - Street 1:15108 DOVEHEART LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-3054
Practice Address - Country:US
Practice Address - Phone:240-461-3008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4018251S00000X
DCPRC14352251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD713424Medicaid