Provider Demographics
NPI:1396055596
Name:MOMENTUM FOR MENTAL HEALTH
Entity type:Organization
Organization Name:MOMENTUM FOR MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPRP
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-286-8988
Mailing Address - Street 1:86 SOUTH 14TH STREET
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112
Mailing Address - Country:US
Mailing Address - Phone:408-938-8500
Mailing Address - Fax:408-286-8988
Practice Address - Street 1:86 SOUTH 14TH STREET
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112
Practice Address - Country:US
Practice Address - Phone:408-938-8500
Practice Address - Fax:408-286-8988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2022-07-14
Deactivation Date:2015-10-07
Deactivation Code:
Reactivation Date:2022-07-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health