Provider Demographics
NPI:1235395096
Name:STEP UP ON SECOND ACT PROGRAM
Entity Type:Organization
Organization Name:STEP UP ON SECOND ACT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL CASE MANGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:715-212-6855
Mailing Address - Street 1:3435 OCEAN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3435 OCEAN PARK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3301
Practice Address - Country:US
Practice Address - Phone:310-392-9474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management