Provider Demographics
NPI:1780819003
Name:PROVISIONS BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:PROVISIONS BEHAVIORAL SERVICES
Other - Org Name:PROVISIONS COMMUNITY SUPPORT SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JANNETTA
Authorized Official - Middle Name:DELOIS
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-308-8366
Mailing Address - Street 1:1504 GILLESPIE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-1846
Mailing Address - Country:US
Mailing Address - Phone:910-308-8366
Mailing Address - Fax:910-424-3453
Practice Address - Street 1:1504 GILLESPIE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-1846
Practice Address - Country:US
Practice Address - Phone:910-308-8366
Practice Address - Fax:910-424-3453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-17
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health