Provider Demographics
NPI:1417277922
Name:JEFFERSON PARISH SERVIE AUTHORITY
Entity Type:Organization
Organization Name:JEFFERSON PARISH SERVIE AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MIKAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-838-5257
Mailing Address - Street 1:2400 EDENBORN AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-1817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 EDENBORN AVE
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1817
Practice Address - Country:US
Practice Address - Phone:504-838-5257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3130251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health