Healthcare Provider Details

I. General information

NPI: 1700266277
Provider Name (Legal Business Name): JAN'S RESIDENTIAL HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2015
Last Update Date: 05/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N HIGH ST
BLACKSTONE VA
23824-1421
US

IV. Provider business mailing address

307 N HIGH ST
BLACKSTONE VA
23824-1421
US

V. Phone/Fax

Practice location:
  • Phone: 434-676-1372
  • Fax: 434-676-1062
Mailing address:
  • Phone: 434-676-1372
  • Fax: 434-676-1062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateVA

VIII. Authorized Official

Name: JUDY BENNETT
Title or Position: ADMINISTRATOR
Credential: ADMINISTRATOR/CNA
Phone: 434-430-0993