MEDICARE: JUSSAFE ADULT FOSTER CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service

General Provider Information

NPI Number	:	1417273350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUSSAFE ADULT FOSTER CARE

Provider Business Mailing Address
First Line	:	8945 PREAKNESS CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3582
Country	:	US
Telephone Number	:	214-680-4815
Fax Number	:

Provider Business Practice Location Address
First Line	:	8945 PREAKNESS CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3582
Country	:	US
Telephone Number	:	214-680-4815
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KRISTINA M ROBERTS-WYNN
Credential	:
Telephone Number	:	214-680-4815

Provider Enumeration Date	:	04/16/2010
Last Update Date	:	04/16/2010

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Directions to “JUSSAFE ADULT FOSTER CARE ” Practice Location

Language	Start Address	Practice Location

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