Basic Information
| Provider Information | |||||||||
| NPI: | 1740561489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JHA HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GOODWIN-LEVINE ADULT DAY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 169 DAVENPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037891650 | ||||||||
| FaxNumber: | 2037891706 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 DAVENPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037891650 | ||||||||
| FaxNumber: | 2037891706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2011 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROLNICK | ||||||||
| AuthorizedOfficialFirstName: | JUDITH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2037891650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | 004072559 | 01 | CT | PERFORMING PROVIDER NUMBER | OTHER |