Basic Information
| Provider Information | |||||||||
| NPI: | 1366740342 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTER FOR FAMILY HEALTH | ||||||||
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| OtherOrganizationName: | JACKSON HIGH TEEN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177485500 | ||||||||
| FaxNumber: | 5177809286 | ||||||||
| Practice Location | |||||||||
| Address1: | 544 WILDWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177800838 | ||||||||
| FaxNumber: | 5177800689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2011 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | KASER | ||||||||
| AuthorizedOfficialFirstName: | MOLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5177485500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041S0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 124Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.