Provider Demographics
NPI:1720551450
Name:KSA YOUTH FOUNDATION INC.
Entity Type:Organization
Organization Name:KSA YOUTH FOUNDATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINS-JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-766-4194
Mailing Address - Street 1:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-0703
Mailing Address - Country:US
Mailing Address - Phone:240-766-4194
Mailing Address - Fax:301-485-0363
Practice Address - Street 1:2829 CHESAPEAKE BEACH RD W
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-9526
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:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility