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General NPI Number Information
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NPI Number | 1265204762
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Entity Type | Organization
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Legal Business Name | MS. JENNIE'S PLACE INC
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Dates
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Enumeration Date | 10/27/2023
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Last Update Date | 10/27/2023
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Provider Practice Location Address
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Address Line | 924 N MAGNOLIA AVE STE 320
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City | ORLANDO
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State | FL
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Zip | 32803-3850
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Country | US
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Telephone | 407-496-6673
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 692286
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City | ORLANDO
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State | FL
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Zip | 32869-2286
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | RANDOLPH BRACY
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Credential |
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Telephone | 407-274-5405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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