Provider Demographics
NPI:1558946731
Name:NDLLJ INC
Entity Type:Organization
Organization Name:NDLLJ INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HONORA
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-697-0497
Mailing Address - Street 1:1507 E VALLEY PKWY STE 3 #360
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1535 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2465
Practice Address - Country:US
Practice Address - Phone:760-697-0497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health