Provider Demographics
NPI:1922379056
Name:THE COOLEY JACKSON FOUNDATION
Entity type:Organization
Organization Name:THE COOLEY JACKSON FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAMONT
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:856-912-9404
Mailing Address - Street 1:1081 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08104-2627
Mailing Address - Country:US
Mailing Address - Phone:856-912-9404
Mailing Address - Fax:
Practice Address - Street 1:1081 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08104-2627
Practice Address - Country:US
Practice Address - Phone:856-912-9404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children