Provider Demographics
NPI:1205600541
Name:MY BROTHERS KEEPER
Entity type:Organization
Organization Name:MY BROTHERS KEEPER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRIE
Authorized Official - Suffix:
Authorized Official - Credentials:PM
Authorized Official - Phone:480-265-8816
Mailing Address - Street 1:4425 E AGAVE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-0620
Mailing Address - Country:US
Mailing Address - Phone:480-265-8816
Mailing Address - Fax:
Practice Address - Street 1:4425 E AGAVE RD STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-0620
Practice Address - Country:US
Practice Address - Phone:480-265-8816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-07
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No101200000XBehavioral Health & Social Service ProvidersDrama TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
No177F00000XOther Service ProvidersLodgingGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No347C00000XTransportation ServicesPrivate Vehicle
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty