Provider Demographics
NPI:1013056167
Name:EAST END INTENSIVE OUTPATIENT PROGRAM
Entity Type:Organization
Organization Name:EAST END INTENSIVE OUTPATIENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MCAID COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:COOPER
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-247-0039
Mailing Address - Street 1:2010 27TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-4912
Mailing Address - Country:US
Mailing Address - Phone:757-247-0039
Mailing Address - Fax:757-247-0158
Practice Address - Street 1:2010 27TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23607-4912
Practice Address - Country:US
Practice Address - Phone:757-247-0039
Practice Address - Fax:757-247-0158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health