Provider Demographics
NPI:1922395748
Name:JEFFERSON TRAIL TREATMENT CENTER FOR CHILDREN
Entity Type:Organization
Organization Name:JEFFERSON TRAIL TREATMENT CENTER FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:TENCH
Authorized Official - Suffix:
Authorized Official - Credentials:BOD
Authorized Official - Phone:615-250-0283
Mailing Address - Street 1:110 WESTWOOD PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5075
Mailing Address - Country:US
Mailing Address - Phone:615-250-0283
Mailing Address - Fax:615-250-0000
Practice Address - Street 1:2101 ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-1521
Practice Address - Country:US
Practice Address - Phone:615-250-0283
Practice Address - Fax:615-250-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA63014001323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000207306Medicaid