Provider Demographics
NPI:1477940419
Name:JUBILEE LEADERSHIP ACADEMY
Entity Type:Organization
Organization Name:JUBILEE LEADERSHIP ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:509-749-2103
Mailing Address - Street 1:29 JUBILEE CIR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:WA
Mailing Address - Zip Code:99348-8607
Mailing Address - Country:US
Mailing Address - Phone:509-749-2103
Mailing Address - Fax:
Practice Address - Street 1:29 JUBILEE CIR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:WA
Practice Address - Zip Code:99348-8607
Practice Address - Country:US
Practice Address - Phone:509-749-2103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health