Healthcare Provider Details

I. General information

NPI: 1366673105
Provider Name (Legal Business Name): JMJ ENTERPRISE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 TEXTILE DR
GREENSBORO NC
27405-5857
US

IV. Provider business mailing address

2020 TEXTILE DR
GREENSBORO NC
27405-5857
US

V. Phone/Fax

Practice location:
  • Phone: 336-271-6982
  • Fax: 336-271-6982
Mailing address:
  • Phone: 336-271-6982
  • Fax: 336-271-6982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberMHL-041-857
License Number StateNC

VIII. Authorized Official

Name: MRS. TRACI DERONN MARTIN
Title or Position: OWNER / EXECUTIVE DIRECTOR
Credential:
Phone: 336-271-6982