Provider Demographics
NPI:1720105992
Name:SPROUT FAMILY SERVICES, INC.
Entity type:Organization
Organization Name:SPROUT FAMILY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-235-6044
Mailing Address - Street 1:3691 BEN WALTERS LN STE 4
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7750
Mailing Address - Country:US
Mailing Address - Phone:907-235-6044
Mailing Address - Fax:907-235-2644
Practice Address - Street 1:3691 BEN WALTERS LN STE 4
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7750
Practice Address - Country:US
Practice Address - Phone:907-235-6044
Practice Address - Fax:907-235-2644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKTC2625Medicaid
AKCMG117Medicaid
AKTC2625Medicaid