Provider Demographics
NPI:1659077287
Name:KSA YOUTH FOUNDATION INC.
Entity Type:Organization
Organization Name:KSA YOUTH FOUNDATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILKINS-JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-766-4194
Mailing Address - Street 1:10905 FORT WASHINGTON RD STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5844
Mailing Address - Country:US
Mailing Address - Phone:240-766-4194
Mailing Address - Fax:301-485-0363
Practice Address - Street 1:10905 FORT WASHINGTON RD STE 105
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5844
Practice Address - Country:US
Practice Address - Phone:240-766-4194
Practice Address - Fax:301-485-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty