Provider Demographics
NPI:1649404708
Name:JEFFERSON COUNTY COMPREHENSIVE
Entity Type:Organization
Organization Name:JEFFERSON COUNTY COMPREHENSIVE
Other - Org Name:SUBSTANCE ABUSE OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOEHMER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC, QMHP
Authorized Official - Phone:618-242-1994
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0054
Mailing Address - Country:US
Mailing Address - Phone:618-242-1994
Mailing Address - Fax:618-242-6392
Practice Address - Street 1:16338 N IL HWY 37
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-242-1994
Practice Address - Fax:618-242-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL002250003251S00000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health