NPIMap

Organization Active NPI

Jefferson County Comprehensive

  • Substance Abuse Rehabilitation Facility
  • Mt Vernon, IL
National Provider Identifier
1649404708
Registry record updated Aug 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Substance Abuse Rehabilitation FacilityTaxonomy code 324500000X
License
002250003 Issued in IL
Legal business name
JEFFERSON COUNTY COMPREHENSIVE
Practice address
16338 N Il Hwy 37
Mt Vernon, IL 62864
Phone
(618) 242-1994
Fax
(618) 242-6392
NPI assigned
May 5, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 17, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Daniel P Boehmer, MA, LCPC, QMHP
Title
Executive Director
Phone
(618) 242-1994

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X 002250003 IL
Substance Abuse Rehabilitation Facility 324500000X 002250003 IL Primary

Addresses

Primary practice location

16338 N Il Hwy 37
Mt Vernon, IL 62864

Mailing address

PO Box 428
Mount Vernon, IL 62864-0054
Phone (618) 242-1994

Other names 1

  • Substance Abuse Outpatient Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050810000128 IL Part B Supplier - Clinic/Group Practice 1153350103 Receives reassigned benefits from 3 practitioners
1 other NPI on this enrollment
Practice locations: Mount Vernon, IL

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1241481600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1534464000000",
    "number": "1649404708",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 428",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628640054",
            "telephone_number": "618-242-1994",
            "fax_number": "618-242-6392"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16338 N IL HWY 37",
            "city": "MT VERNON",
            "state": "IL",
            "postal_code": "62864",
            "telephone_number": "618-242-1994",
            "fax_number": "618-242-6392"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON COUNTY COMPREHENSIVE",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-05-05",
        "last_updated": "2018-08-17",
        "status": "A",
        "authorized_official_last_name": "BOEHMER",
        "authorized_official_first_name": "DANIEL",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "618-242-1994",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MA, LCPC, QMHP"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "IL",
            "license": "002250003",
            "primary": false
        },
        {
            "code": "324500000X",
            "taxonomy_group": "",
            "desc": "Substance Abuse Rehabilitation Facility",
            "state": "IL",
            "license": "002250003",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Substance Abuse Outpatient",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Substance Abuse Outpatient",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Mt Vernon, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.