Provider Demographics
NPI:1194974642
Name:JAMAICAN MOON GROUP, LLC
Entity type:Organization
Organization Name:JAMAICAN MOON GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOUTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-222-2100
Mailing Address - Street 1:930 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3644
Mailing Address - Country:US
Mailing Address - Phone:214-222-2100
Mailing Address - Fax:
Practice Address - Street 1:1050 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-2444
Practice Address - Country:US
Practice Address - Phone:214-330-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty