Provider Demographics
NPI:1407029879
Name:JANESVILLE COMMUNITY SUPPORT PROGRAM
Entity Type:Organization
Organization Name:JANESVILLE COMMUNITY SUPPORT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-757-5204
Mailing Address - Street 1:35 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-3922
Mailing Address - Country:US
Mailing Address - Phone:608-757-5566
Mailing Address - Fax:
Practice Address - Street 1:35 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3922
Practice Address - Country:US
Practice Address - Phone:608-757-5566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROCK COUNTY HUMAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43420100Medicaid