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General NPI Number Information
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NPI Number | 1578015921
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Entity Type | Organization
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Legal Business Name | JUBILATION HOUSE, LLC
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Dates
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Enumeration Date | 11/02/2016
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Last Update Date | 11/02/2016
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Provider Practice Location Address
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Address Line | 165 CONSTELLATIONS RD
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City | IDAHO FALLS
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State | ID
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Zip | 83402-4988
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Country | US
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Telephone | 801-836-6275
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Fax |
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Provider Business Mailing Address
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Address Line | 3144 TIPPERARY LN
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7323
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Country | US
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Telephone | 801-836-6275
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | MARK BROWNING
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Credential |
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Telephone | 801-836-6275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | RC-1125
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number | RC-1125
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | RC-1125
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License Number State | ID
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