Provider Demographics
NPI:1497852768
Name:THE DEVEREUX FOUNDATION
Entity type:Organization
Organization Name:THE DEVEREUX FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-576-5765
Mailing Address - Street 1:4000 N CENTRAL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3520
Mailing Address - Country:US
Mailing Address - Phone:602-283-1573
Mailing Address - Fax:480-443-5587
Practice Address - Street 1:6436 E SWEETWATER AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4581
Practice Address - Country:US
Practice Address - Phone:480-998-2920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-246322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ599904OtherAHCCCS ID