Provider Demographics
NPI:1285959312
Name:FOUNTAIN THERAPEUTIC AND SUPPORTIVE SERVICES LLC
Entity type:Organization
Organization Name:FOUNTAIN THERAPEUTIC AND SUPPORTIVE SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:JINOR
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:301-437-9666
Mailing Address - Street 1:108 CARDIFF CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7864
Mailing Address - Country:US
Mailing Address - Phone:301-437-9666
Mailing Address - Fax:
Practice Address - Street 1:108 CARDIFF CT # CY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7864
Practice Address - Country:US
Practice Address - Phone:301-437-9666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500788521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty