Provider Demographics
NPI:1871890871
Name:GENESIS YOUTH AND FAMILY SERVICES OF LA, LLC
Entity type:Organization
Organization Name:GENESIS YOUTH AND FAMILY SERVICES OF LA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-253-3752
Mailing Address - Street 1:PO BOX 42915
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-0017
Mailing Address - Country:US
Mailing Address - Phone:225-932-0200
Mailing Address - Fax:225-932-0201
Practice Address - Street 1:5700 FLORIDA BLVD
Practice Address - Street 2:SUITE 412
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4274
Practice Address - Country:US
Practice Address - Phone:225-932-0200
Practice Address - Fax:225-932-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health