Provider Demographics
NPI:1568766905
Name:SAINT JOSHUAS THERAPEUTIC GROUP HOME INC
Entity Type:Organization
Organization Name:SAINT JOSHUAS THERAPEUTIC GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:T
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-316-4822
Mailing Address - Street 1:4078 PINE HILL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5738
Mailing Address - Country:US
Mailing Address - Phone:769-257-5466
Mailing Address - Fax:866-224-2940
Practice Address - Street 1:3409 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-3136
Practice Address - Country:US
Practice Address - Phone:769-257-5466
Practice Address - Fax:866-224-2940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06071213322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children