Provider Demographics
NPI:1306232632
Name:JACKSON COUNTY YOUTH CENTER
Entity Type:Organization
Organization Name:JACKSON COUNTY YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEREMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:517-768-2778
Mailing Address - Street 1:930 FLEMING AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2534
Mailing Address - Country:US
Mailing Address - Phone:517-788-4460
Mailing Address - Fax:517-788-4661
Practice Address - Street 1:930 FLEMING AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2534
Practice Address - Country:US
Practice Address - Phone:517-788-4460
Practice Address - Fax:517-788-4661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICO380201204252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency