Provider Demographics
NPI:1063565901
Name:JEFFERSON C-123 SCHOOL
Entity type:Organization
Organization Name:JEFFERSON C-123 SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:DOWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-944-2316
Mailing Address - Street 1:37614 US HIGHWAY 136
Mailing Address - Street 2:
Mailing Address - City:CONCEPTION JUNCTION
Mailing Address - State:MO
Mailing Address - Zip Code:64434-8109
Mailing Address - Country:US
Mailing Address - Phone:660-944-2316
Mailing Address - Fax:660-944-2315
Practice Address - Street 1:37614 US HIGHWAY 136
Practice Address - Street 2:
Practice Address - City:CONCEPTION JUNCTION
Practice Address - State:MO
Practice Address - Zip Code:64434-8109
Practice Address - Country:US
Practice Address - Phone:660-944-2316
Practice Address - Fax:660-944-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO506127802251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506127802Medicaid