Provider Demographics
NPI:1023637345
Name:DAWSON, JAMIE ROSHUN
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:ROSHUN
Last Name:DAWSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.
Mailing Address - Street 2:PO BOX 86537
Mailing Address - City:TUSCON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13229 S 48TH ST APT 3051
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044
Practice Address - Country:US
Practice Address - Phone:501-952-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10125986385HR2055X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10125986OtherAZ DEPT OF HEALTH SERVICES
AZ1023637345OtherTHERAPEUTIC FOSTER CARE