Provider Demographics
NPI:1831134501
Name:JACKSON-VINTON COMMUNITY ACTION, INC.
Entity type:Organization
Organization Name:JACKSON-VINTON COMMUNITY ACTION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:THIESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-384-3722
Mailing Address - Street 1:118 S NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-1540
Mailing Address - Country:US
Mailing Address - Phone:740-384-3722
Mailing Address - Fax:740-384-5405
Practice Address - Street 1:118 S NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-1540
Practice Address - Country:US
Practice Address - Phone:740-384-3722
Practice Address - Fax:740-384-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0319113Medicaid
OH0319113Medicaid