Provider Demographics
NPI:1457997280
Name:VILLAGE MENTORS
Entity Type:Organization
Organization Name:VILLAGE MENTORS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERMAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:480-313-4770
Mailing Address - Street 1:4903 E DIXON CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-6453
Mailing Address - Country:US
Mailing Address - Phone:480-313-4770
Mailing Address - Fax:
Practice Address - Street 1:4903 E DIXON CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-6453
Practice Address - Country:US
Practice Address - Phone:480-313-4770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health