Basic Information
Provider Information | |||||||||
NPI: | 1861447526 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STATE OF MISSOURI | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHEAST MO MENTAL HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1706 E ELM ST | ||||||||
Address2: |   | ||||||||
City: | JEFFERSON CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 651014130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737513398 | ||||||||
FaxNumber: | 5735264560 | ||||||||
Practice Location | |||||||||
Address1: | 1010 W COLUMBIA ST | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | MO | ||||||||
PostalCode: | 636402902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5732186792 | ||||||||
FaxNumber: | 5732186703 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 09/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOECKMANN | ||||||||
AuthorizedOfficialFirstName: | MOLLY | ||||||||
AuthorizedOfficialMiddleName: | JANE | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMINISTRATIVE SERVICES | ||||||||
AuthorizedOfficialTelephone: | 5737514055 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | STATE OF MISSOURI | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X |   |   | Y |   | Hospitals | Psychiatric Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 050490200 | 05 | MO |   | MEDICAID |