Healthcare Provider Details

I. General information

NPI: 1205741394
Provider Name (Legal Business Name): JAKES PLACE GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33023 HARVEST DR
CARRSVILLE VA
23315-2123
US

IV. Provider business mailing address

33023 HARVEST DR
CARRSVILLE VA
23315-2123
US

V. Phone/Fax

Practice location:
  • Phone: 757-641-4832
  • Fax:
Mailing address:
  • Phone: 757-641-4832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. TINA MARIE EVANS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 757-641-4832