Provider Demographics
NPI:1922518125
Name:LJ INDEPENDENT SERVICES INC.
Entity Type:Organization
Organization Name:LJ INDEPENDENT SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSED
Authorized Official - Phone:917-594-7948
Mailing Address - Street 1:40 MEMORIAL HWY APT 14H
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-8326
Mailing Address - Country:US
Mailing Address - Phone:917-504-7948
Mailing Address - Fax:
Practice Address - Street 1:40 MEMORIAL HWY APT 14H
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-8326
Practice Address - Country:US
Practice Address - Phone:917-504-7948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109522413252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1518229707Medicaid