Healthcare Provider Details

I. General information

NPI: 1285521922
Provider Name (Legal Business Name): JENESIS LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 AMANDA CT NW
CEDAR RAPIDS IA
52405-1961
US

IV. Provider business mailing address

3403 AMANDA CT NW
CEDAR RAPIDS IA
52405-1961
US

V. Phone/Fax

Practice location:
  • Phone: 269-999-0321
  • Fax:
Mailing address:
  • Phone: 269-999-0321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JACKLINE MMBAGA
Title or Position: MANAGING MEMBER
Credential:
Phone: 269-285-3352