Provider Demographics
NPI:1376908921
Name:JUMP START LLC MATERNAL INFANT HEALTH PROGRAM
Entity Type:Organization
Organization Name:JUMP START LLC MATERNAL INFANT HEALTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MATERNAL INFANT HEALTH PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-587-2963
Mailing Address - Street 1:1086 WILLIAMSON CIR
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-3314
Mailing Address - Country:US
Mailing Address - Phone:313-587-2963
Mailing Address - Fax:
Practice Address - Street 1:1086 WILLIAMSON CIR
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340
Practice Address - Country:US
Practice Address - Phone:313-587-2963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI302F00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization