Healthcare Provider Details

I. General information

NPI: 1710788419
Provider Name (Legal Business Name): JEANETTES SANCTUARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38780 CHESTNUT RIDGE RD
ELYRIA OH
44035-8232
US

IV. Provider business mailing address

113 LEXINGTON AVE
ELYRIA OH
44035-6217
US

V. Phone/Fax

Practice location:
  • Phone: 440-219-4004
  • Fax:
Mailing address:
  • Phone: 440-657-6446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. LATASHA MONIQUE GORDON
Title or Position: FOUNDER/CEO
Credential: LPC, LICDC, OCPSA
Phone: 440-657-6446