MEDICARE: HATTIE JEAN HOME HEALTH LLC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1417715061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HATTIE JEAN HOME HEALTH LLC

Provider Business Mailing Address
First Line	:	345 HIGH ST NE
Second Line	:
City	:	WARREN
State	:	OH
Zip	:	44481-1248
Country	:	US
Telephone Number	:	330-980-3570
Fax Number	:

Provider Business Practice Location Address
First Line	:	345 HIGH ST NE
Second Line	:
City	:	WARREN
State	:	OH
Zip	:	44481-1248
Country	:	US
Telephone Number	:	330-980-3570
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TANIKA MONIQUE BRECKENRIDGE
Credential	:
Telephone Number	:	330-881-1741

Provider Enumeration Date	:	03/08/2024
Last Update Date	:	03/08/2024

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