Provider Demographics
NPI:1649950296
Name:SANCTUM HEALTH PARTNERS, LLC
Entity type:Organization
Organization Name:SANCTUM HEALTH PARTNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-298-3298
Mailing Address - Street 1:2121 MIDWAY RD STE 145
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-5263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 MIDWAY RD STE 145
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-5263
Practice Address - Country:US
Practice Address - Phone:972-851-1022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-19
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA3000XAmbulatory Health Care FacilitiesClinic/CenterAugmentative Communication
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental DisabilitiesGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3930695Medicaid