Provider Demographics
NPI:1174629810
Name:JAMES PARK HEALTHCARE INC
Entity Type:Organization
Organization Name:JAMES PARK HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:REESE
Authorized Official - Last Name:COVINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-399-3336
Mailing Address - Street 1:PO BOX 692
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-0692
Mailing Address - Country:US
Mailing Address - Phone:973-399-3336
Mailing Address - Fax:
Practice Address - Street 1:5 STUYVESANT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-1711
Practice Address - Country:US
Practice Address - Phone:973-399-3336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA038265101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021717Medicaid
NJ0021717Medicaid