Healthcare Provider Details

I. General information

NPI: 1255401162
Provider Name (Legal Business Name): PUTNAM-JASPER ASSOC. FOR MENTALLY HANDICAPPED, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 SARA LEE DRIVE
EATONTON GA
31024-3115
US

IV. Provider business mailing address

PO BOX 3115
EATONTON GA
31024-3115
US

V. Phone/Fax

Practice location:
  • Phone: 706-485-8391
  • Fax: 706-485-0066
Mailing address:
  • Phone: 706-485-8391
  • Fax: 706-485-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberH202329
License Number StateGA

VIII. Authorized Official

Name: MR. JOHN N. COPELAN
Title or Position: DIRECTOR
Credential:
Phone: 706-485-8391