Healthcare Provider Details

I. General information

NPI: 1730901943
Provider Name (Legal Business Name): DIVINE SUPPORT SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 PLAZA DR # D-2
JACKSONVILLE NC
28540-5068
US

IV. Provider business mailing address

5116 WESTERN BLVD APT 523
JACKSONVILLE NC
28546-0014
US

V. Phone/Fax

Practice location:
  • Phone: 800-622-1325
  • Fax:
Mailing address:
  • Phone: 800-622-1325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. RACHEL JORDAN
Title or Position: CEO
Credential: DHA
Phone: 800-622-1325