Provider Demographics
NPI:1124246244
Name:PROVIDENCE
Entity type:Organization
Organization Name:PROVIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:NAKITA
Authorized Official - Last Name:JONES-MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:BSW, MPA
Authorized Official - Phone:661-822-8223
Mailing Address - Street 1:43545 KIRKLAND AVE
Mailing Address - Street 2:APT.36
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4668
Mailing Address - Country:US
Mailing Address - Phone:661-948-7830
Mailing Address - Fax:
Practice Address - Street 1:43545 KIRKLAND AVE
Practice Address - Street 2:APT.36
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4668
Practice Address - Country:US
Practice Address - Phone:661-948-7830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management