Provider Demographics
NPI:1043414022
Name:DCCCA, INC
Entity type:Organization
Organization Name:DCCCA, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KERYE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, CMA
Authorized Official - Phone:785-841-4138
Mailing Address - Street 1:3312 CLINTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-3624
Mailing Address - Country:US
Mailing Address - Phone:913-894-0900
Mailing Address - Fax:913-894-0908
Practice Address - Street 1:12351 W 96TH TER
Practice Address - Street 2:SUITE 300
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-4409
Practice Address - Country:US
Practice Address - Phone:913-894-0900
Practice Address - Fax:913-894-0908
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DCCCA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-13
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261QM0801X
KS00590942261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS00590942OtherAAPS