Provider Demographics
NPI:1689628190
Name:CATHOLIC CHARITIES OF JACKSON, LENAWEE AND HILLSDALE COUNTIES
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES OF JACKSON, LENAWEE AND HILLSDALE COUNTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-782-2551
Mailing Address - Street 1:1522 JOY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-1933
Mailing Address - Country:US
Mailing Address - Phone:517-782-2551
Mailing Address - Fax:517-783-1986
Practice Address - Street 1:1522 JOY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-1933
Practice Address - Country:US
Practice Address - Phone:517-782-2551
Practice Address - Fax:517-783-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QM0850X
MI788341261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP23230Medicare ID - Type Unspecified