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General NPI Number Information
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NPI Number | 1093850620
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Entity Type | Organization
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Legal Business Name | JAG'S RESIDENTIAL SERVICES, LLC
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 09/08/2021
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Provider Practice Location Address
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Address Line | 1005 LAUREL LEAF RD
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City | ZEBULON
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State | NC
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Zip | 27597
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Country | US
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Telephone | 919-426-3752
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Fax | 919-404-1515
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Provider Business Mailing Address
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Address Line | 1006 LAUREL LEAF RD
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City | ZEBULON
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State | NC
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Zip | 27597
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Country | US
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Telephone | 919-426-3752
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Fax | 919-404-1515
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Authorized Official
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Title or Position | OWNER / DIRECTOR
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Name | MRS. GWENDOLYN GOOLSBY JOHNS
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Credential |
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Telephone | 919-426-3752
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | MHL-092-639
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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