Provider Demographics
NPI:1205285186
Name:JEFFERSON COUNTY COMPREHENSIVE SERVICES VOCATIONAL
Entity type:Organization
Organization Name:JEFFERSON COUNTY COMPREHENSIVE SERVICES VOCATIONAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLSAPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:EXECUTIVE DIRECTOR
Authorized Official - Phone:618-242-1510
Mailing Address - Street 1:16338 N IL HIGHWAY 37
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8178
Mailing Address - Country:US
Mailing Address - Phone:618-242-1510
Mailing Address - Fax:618-242-6392
Practice Address - Street 1:16352 N IL HIGHWAY 37
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-8178
Practice Address - Country:US
Practice Address - Phone:618-244-1510
Practice Address - Fax:618-242-6392
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COUNTY COMPREHENSIVE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL199200159S251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid