Provider Demographics
NPI:1679016554
Name:FRED JEFFERSON MEMORIAL HOME FOR BOYS
Entity Type:Organization
Organization Name:FRED JEFFERSON MEMORIAL HOME FOR BOYS
Other - Org Name:FRED JEFFERSON MEMORIAL HOME #1
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NIQUELLE
Authorized Official - Middle Name:DEONDREA
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:310-763-1660
Mailing Address - Street 1:152 W WALNUT ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3141
Mailing Address - Country:US
Mailing Address - Phone:310-763-1660
Mailing Address - Fax:310-763-0357
Practice Address - Street 1:1000 W 152ND ST
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-2821
Practice Address - Country:US
Practice Address - Phone:310-763-1660
Practice Address - Fax:310-763-0357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children