Provider Demographics
NPI:1275987307
Name:1 PRIORITY INDEPENDENT LIVING SKILLS BUILDING
Entity Type:Organization
Organization Name:1 PRIORITY INDEPENDENT LIVING SKILLS BUILDING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKOSN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:504-208-9636
Mailing Address - Street 1:321 W JUDGE PEREZ DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-4903
Mailing Address - Country:US
Mailing Address - Phone:504-208-9636
Mailing Address - Fax:504-272-2446
Practice Address - Street 1:321 W JUDGE PEREZ DR
Practice Address - Street 2:SUITE B
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-4903
Practice Address - Country:US
Practice Address - Phone:504-208-9636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1548408958251S00000X
LA1364878251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health