Healthcare Provider Details

I. General information

NPI: 1801170139
Provider Name (Legal Business Name): JENESIS CARE HOMES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8234 S SANDUSKY AVE
TULSA OK
74137-1833
US

IV. Provider business mailing address

528 E READING ST
TULSA OK
74106-4326
US

V. Phone/Fax

Practice location:
  • Phone: 918-629-9354
  • Fax: 832-487-8009
Mailing address:
  • Phone: 918-629-9354
  • Fax: 832-487-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberRC7272-7272
License Number StateOK

VIII. Authorized Official

Name: MR. RANDY JACKSON
Title or Position: PRESIDENT
Credential:
Phone: 918-629-9354