Provider Demographics
NPI:1760505523
Name:MESA DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:MESA DEVELOPMENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-256-8618
Mailing Address - Street 1:950 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-3451
Mailing Address - Country:US
Mailing Address - Phone:970-243-3702
Mailing Address - Fax:970-243-7751
Practice Address - Street 1:790 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6126
Practice Address - Country:US
Practice Address - Phone:970-243-3702
Practice Address - Fax:970-243-7751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09000415Medicaid