Provider Demographics
NPI:1104112655
Name:HAVASUPAI TRIBE HEAD START
Entity type:Organization
Organization Name:HAVASUPAI TRIBE HEAD START
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIYUJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-448-2821
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SUPAI
Mailing Address - State:AZ
Mailing Address - Zip Code:86435-0130
Mailing Address - Country:US
Mailing Address - Phone:928-448-2821
Mailing Address - Fax:928-448-2341
Practice Address - Street 1:130 MAIN ST.
Practice Address - Street 2:
Practice Address - City:SUPAI
Practice Address - State:AZ
Practice Address - Zip Code:86435-0130
Practice Address - Country:US
Practice Address - Phone:928-448-2821
Practice Address - Fax:928-448-2341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty