Basic Information
| Provider Information | |||||||||
| NPI: | 1316009145 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEWISH FAMILY & CHILDRENS SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 N 7TH ST | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850143653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022797655 | ||||||||
| FaxNumber: | 6022415756 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 W TALAVI BLVD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234868202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 03/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | LORRIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 6022797655 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD, MBA, LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | OTC6217 | AZ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 007486 | 05 | AZ | MEDICAID |