Basic Information
| Provider Information | |||||||||
| NPI: | 1003418435 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KANGAROO JOURNEYS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 859 FORTUNEGATE DR | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430813521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144048686 | ||||||||
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| Practice Location | |||||||||
| Address1: | 859 FORTUNEGATE DR | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430813521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144048686 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2020 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | JARED | ||||||||
| AuthorizedOfficialFirstName: | CARA | ||||||||
| AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6144048686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1952670739 | 01 | PRIVATE INSURANCE | OTHER |