Provider Demographics
NPI:1295039220
Name:TREC BADLANDS PRENATAL TO FIVE HEAD START
Entity Type:Organization
Organization Name:TREC BADLANDS PRENATAL TO FIVE HEAD START
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,MBA
Authorized Official - Phone:605-723-8837
Mailing Address - Street 1:101 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-1139
Mailing Address - Country:US
Mailing Address - Phone:605-723-8837
Mailing Address - Fax:605-723-8834
Practice Address - Street 1:101 5TH AVE
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-1139
Practice Address - Country:US
Practice Address - Phone:605-723-8837
Practice Address - Fax:605-723-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD=========OtherHEAD START