Provider Demographics
NPI:1699879163
Name:JACKSON NORTH COMMUNITY MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:JACKSON NORTH COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER/CASE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUKUBA
Authorized Official - Middle Name:F
Authorized Official - Last Name:BOBMANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-223-3644
Mailing Address - Street 1:20201 NW 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33056-1755
Mailing Address - Country:US
Mailing Address - Phone:786-223-3644
Mailing Address - Fax:
Practice Address - Street 1:20201 NW 37TH AVE
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33056-1755
Practice Address - Country:US
Practice Address - Phone:786-223-3644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251B00000X251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid