Provider Demographics
NPI:1255744371
Name:JEREMIAH COMMUNITY OUTREACH SERVICES, INC
Entity type:Organization
Organization Name:JEREMIAH COMMUNITY OUTREACH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GOLLADAY
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:708-914-4248
Mailing Address - Street 1:935 175TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2049
Mailing Address - Country:US
Mailing Address - Phone:708-914-4248
Mailing Address - Fax:708-991-2975
Practice Address - Street 1:935 175TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2049
Practice Address - Country:US
Practice Address - Phone:708-914-4248
Practice Address - Fax:708-991-2975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA52410001A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health