Provider Demographics
NPI:1538641568
Name:KINGS & QUEENS YOUTH PROGRAM
Entity Type:Organization
Organization Name:KINGS & QUEENS YOUTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MSCJ, QMHS, CDCA
Authorized Official - Phone:419-206-9023
Mailing Address - Street 1:3550 EXECUTIVE PKWY STE 7-189
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1379
Mailing Address - Country:US
Mailing Address - Phone:419-206-9023
Mailing Address - Fax:
Practice Address - Street 1:430 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-8540
Practice Address - Country:US
Practice Address - Phone:419-671-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management