Provider Demographics
NPI:1962999326
Name:STATEWIDE HEALTHCARE SERVICES
Entity type:Organization
Organization Name:STATEWIDE HEALTHCARE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-795-4683
Mailing Address - Street 1:1 N STATE ST STE 800
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3312
Mailing Address - Country:US
Mailing Address - Phone:312-795-4683
Mailing Address - Fax:312-704-1126
Practice Address - Street 1:3828 I 55 N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-6324
Practice Address - Country:US
Practice Address - Phone:601-982-7311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health