Healthcare Provider Details

I. General information

NPI: 1790546901
Provider Name (Legal Business Name): DEAR JAFFA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 FELLOWSHIP ROAD, EAST GATE CENTER SUITE 200
MOUNT LAUREL NJ
08054
US

IV. Provider business mailing address

76 SISTERS FARMSTEAD DR
MOUNT LAUREL NJ
08054-1448
US

V. Phone/Fax

Practice location:
  • Phone: 347-458-5494
  • Fax:
Mailing address:
  • Phone: 347-458-5494
  • 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 Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHIMARA WATSON
Title or Position: PRESIDENT
Credential:
Phone: 347-458-5494