Provider Demographics
NPI:1578635462
Name:MENTAL HEALTH & RECOVERY SERVICES OF JACKSON HOLE
Entity Type:Organization
Organization Name:MENTAL HEALTH & RECOVERY SERVICES OF JACKSON HOLE
Other - Org Name:JACKSON HOLE COMMUNITY COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEIDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-733-2046
Mailing Address - Street 1:PO BOX 1868
Mailing Address - Street 2:640 EAST BROADWAY
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1868
Mailing Address - Country:US
Mailing Address - Phone:307-733-2046
Mailing Address - Fax:307-733-6289
Practice Address - Street 1:640 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-2046
Practice Address - Fax:307-733-6289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00708001OtherBLUSE CROSS BLUE SHIELD
WY106872504Medicaid
WA106872503Medicaid
WY106872500Medicaid