Provider Demographics
NPI:1639493406
Name:JUSSAMAL MANOR
Entity Type:Organization
Organization Name:JUSSAMAL MANOR
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:NJUGUNA
Authorized Official - Last Name:MARIRA
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:480-559-5991
Mailing Address - Street 1:1302 W KESLER LN
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7286
Mailing Address - Country:US
Mailing Address - Phone:480-559-5991
Mailing Address - Fax:480-268-7738
Practice Address - Street 1:1302 W KESLER LN
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-7286
Practice Address - Country:US
Practice Address - Phone:480-559-5991
Practice Address - Fax:480-268-7738
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NONE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3531103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty