Provider Demographics
NPI:1548327810
Name:TKJ LLC
Entity type:Organization
Organization Name:TKJ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:QUE
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-943-1860
Mailing Address - Street 1:2413 ROYAL LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-6453
Mailing Address - Country:US
Mailing Address - Phone:801-943-1860
Mailing Address - Fax:801-942-5094
Practice Address - Street 1:2413 ROYAL LN
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6453
Practice Address - Country:US
Practice Address - Phone:801-943-1860
Practice Address - Fax:801-942-5094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11803320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========002Medicaid
UT=========001Medicaid