Provider Demographics
NPI:1699820720
Name:FAMILY & CHILDRENS SERVICE OF FORT WAYNE INC
Entity Type:Organization
Organization Name:FAMILY & CHILDRENS SERVICE OF FORT WAYNE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-744-4326
Mailing Address - Street 1:2712 S CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2712 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1402
Practice Address - Country:US
Practice Address - Phone:260-744-4326
Practice Address - Fax:260-744-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8020ASR251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200090360Medicaid
IN146530Medicare ID - Type Unspecified