Provider Demographics
NPI:1275788408
Name:SOUTHEASTERN HUMAN SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN HUMAN SERVICES
Other - Org Name:COUNTRY VIEW ESTATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-616-1456
Mailing Address - Street 1:121 STONEBRIDGE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2160
Mailing Address - Country:US
Mailing Address - Phone:731-660-5311
Mailing Address - Fax:731-660-0987
Practice Address - Street 1:1895 HIGHWAY 138
Practice Address - Street 2:
Practice Address - City:TOONE
Practice Address - State:TN
Practice Address - Zip Code:38381-8128
Practice Address - Country:US
Practice Address - Phone:731-658-4629
Practice Address - Fax:731-659-2999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL219-107-6738320600000X
TNL219-107-6737320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities