Provider Demographics
NPI:1134309438
Name:KEYSTONE DJJ, LLC
Entity Type:Organization
Organization Name:KEYSTONE DJJ, LLC
Other - Org Name:BRISTOL YOUTH ACADEMY
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:850-643-4600
Mailing Address - Street 1:12422 NW G T REVELL RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-3007
Mailing Address - Country:US
Mailing Address - Phone:850-643-4600
Mailing Address - Fax:850-643-2061
Practice Address - Street 1:12422 NW G T REVELL RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-3007
Practice Address - Country:US
Practice Address - Phone:850-643-4600
Practice Address - Fax:850-643-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0239AD272501OtherOUTPATIENT SUBSTANCE ABUS