Healthcare Provider Details

I. General information

NPI: 1629208699
Provider Name (Legal Business Name): JABEZ RESIDENTIAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 TILGHMAN STREET
KENLY NC
27542-1214
US

IV. Provider business mailing address

PO BOX 1214
KENLY NC
27542-1214
US

V. Phone/Fax

Practice location:
  • Phone: 919-284-3723
  • Fax:
Mailing address:
  • Phone: 919-284-3723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL051174
License Number StateNC

VIII. Authorized Official

Name: DAMIEN K FORSYTHE
Title or Position: OWNER
Credential:
Phone: 919-284-3723