Healthcare Provider Details

I. General information

NPI: 1578015921
Provider Name (Legal Business Name): JUBILATION HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 CONSTELLATIONS RD
IDAHO FALLS ID
83402-4988
US

IV. Provider business mailing address

3144 TIPPERARY LN
IDAHO FALLS ID
83404-7323
US

V. Phone/Fax

Practice location:
  • Phone: 801-836-6275
  • Fax:
Mailing address:
  • Phone: 801-836-6275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberRC-1125
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberRC-1125
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License NumberRC-1125
License Number StateID

VIII. Authorized Official

Name: MARK BROWNING
Title or Position: PARTNER
Credential:
Phone: 801-836-6275