Provider Demographics
NPI:1235780982
Name:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Entity Type:Organization
Organization Name:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-956-9508
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:109 CALIFORNIA ST
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-519-9200
Mailing Address - Fax:618-985-4635
Practice Address - Street 1:1006 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1539
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:618-985-3774
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone