Provider Demographics
NPI:1326211616
Name:JESSE CALLOWAY'S FAMILY SERVICES
Entity Type:Organization
Organization Name:JESSE CALLOWAY'S FAMILY SERVICES
Other - Org Name:JESSE JAMES-DIR
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MENTAL THERAPIST
Authorized Official - Phone:434-229-1912
Mailing Address - Street 1:1129 COSBY STREET
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504
Mailing Address - Country:US
Mailing Address - Phone:434-229-1912
Mailing Address - Fax:
Practice Address - Street 1:1129 COSBY ST
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24504
Practice Address - Country:US
Practice Address - Phone:434-229-1912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA31205001302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4944216Medicaid