Provider Demographics
NPI:1205401593
Name:JR'S TRAUMA CARE INITIATIVE
Entity Type:Organization
Organization Name:JR'S TRAUMA CARE INITIATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MENTAL HEALTH
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ELMER
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:619-330-7569
Mailing Address - Street 1:654 E SAN YSIDRO BLVD UNIT 483
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-3151
Mailing Address - Country:US
Mailing Address - Phone:619-330-7569
Mailing Address - Fax:
Practice Address - Street 1:1665 PRECISION PARK LN STE H
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-1348
Practice Address - Country:US
Practice Address - Phone:619-330-7569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health