Healthcare Provider Details

I. General information

NPI: 1831034982
Provider Name (Legal Business Name): OJ SUPPORT LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W PARKWOOD ST
SIDNEY OH
45365-3612
US

IV. Provider business mailing address

410 W PARKWOOD ST
SIDNEY OH
45365-3612
US

V. Phone/Fax

Practice location:
  • Phone: 937-409-8633
  • Fax:
Mailing address:
  • Phone: 937-409-8633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: OUSMAN JATTA
Title or Position: MANAGING MEMBER
Credential: CEO
Phone: 937-658-8754