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General NPI Number Information
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NPI Number | 1528434149
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Entity Type | Organization
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Legal Business Name | THE JERICHO HOUSE
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Dates
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Enumeration Date | 08/18/2015
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Last Update Date | 03/30/2016
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Provider Practice Location Address
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Address Line | 6757 DUNCAN BRIDGE RD
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City | CLEVELAND
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State | GA
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Zip | 30528-5170
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Country | US
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Telephone | 706-878-0015
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Fax | 706-878-0037
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Provider Business Mailing Address
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Address Line | 3621 HIGHWAY 255 N
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City | SAUTEE NACOOCHEE
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State | GA
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Zip | 30571-2622
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Country | US
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Telephone | 706-878-0015
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Fax | 706-878-0037
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Authorized Official
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Title or Position | PRESIDENT
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Name | LARRY MCKENNA
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Credential |
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Telephone | 706-878-0015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State | GA
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