Provider Demographics
NPI:1790130508
Name:JEFFERSON DAY REPORT CENTER, INC.
Entity Type:Organization
Organization Name:JEFFERSON DAY REPORT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-728-3257
Mailing Address - Street 1:130 E BURR BLVD FL 1
Mailing Address - Street 2:
Mailing Address - City:KEARNEYSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25430-4788
Mailing Address - Country:US
Mailing Address - Phone:304-728-3527
Mailing Address - Fax:304-728-3614
Practice Address - Street 1:130 E BURR BLVD FL 1
Practice Address - Street 2:
Practice Address - City:KEARNEYSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25430-4788
Practice Address - Country:US
Practice Address - Phone:304-728-3527
Practice Address - Fax:304-728-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-29
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV521103TC0700X
WV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty