Healthcare Provider Details

I. General information

NPI: 1407732837
Provider Name (Legal Business Name): LIFE HOUSE REENTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 12/28/2025
Certification Date: 12/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 HURLEY WAY STE 185D
SACRAMENTO CA
95825-3223
US

IV. Provider business mailing address

2020 HURLEY WAY STE 185D
SACRAMENTO CA
95825-3223
US

V. Phone/Fax

Practice location:
  • Phone: 855-454-3387
  • Fax:
Mailing address:
  • Phone: 855-454-3387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JULIUS JACKSON
Title or Position: CEO
Credential:
Phone: 707-816-0640