Provider Demographics
NPI:1164701603
Name:MH CLINIC AT JUVENILE HALL
Entity Type:Organization
Organization Name:MH CLINIC AT JUVENILE HALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN-CRETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-792-3910
Mailing Address - Street 1:210 S 1ST ST UNIT 412
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95113-2724
Mailing Address - Country:US
Mailing Address - Phone:559-347-8001
Mailing Address - Fax:
Practice Address - Street 1:840 GUADALUPE PKWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-1714
Practice Address - Country:US
Practice Address - Phone:408-299-3166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare