Provider Demographics
NPI:1326202037
Name:JACK LONDON CONTINUATION SCHOOL
Entity Type:Organization
Organization Name:JACK LONDON CONTINUATION SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:BA LIBERAL ARTS
Authorized Official - Phone:818-787-4151
Mailing Address - Street 1:14558 SYLVAN ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-2324
Mailing Address - Country:US
Mailing Address - Phone:818-787-4151
Mailing Address - Fax:818-787-2840
Practice Address - Street 1:12924 OXNARD ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-4104
Practice Address - Country:US
Practice Address - Phone:818-787-4151
Practice Address - Fax:818-787-2840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAN NUYS ALCOHOL & DRUG TREATMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190327AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility