Provider Demographics
NPI:1700010154
Name:JAGGED ROCK REHAB TRAVELERS
Entity Type:Organization
Organization Name:JAGGED ROCK REHAB TRAVELERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUMBOPOISSANT
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:605-430-9361
Mailing Address - Street 1:10667 S AVENUE 10 E # 46
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-7008
Mailing Address - Country:US
Mailing Address - Phone:605-430-9361
Mailing Address - Fax:
Practice Address - Street 1:10667 S AVENUE 10 E # 46
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-7008
Practice Address - Country:US
Practice Address - Phone:605-430-9361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDDD704011252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3025OtherARIZONA DEPARTMENT OF ECONOMIC SECURITY DIVISION OF DEVELOPMENTAL DISABILITIES