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General NPI Number Information
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NPI Number | 1710788419
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Entity Type | Organization
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Legal Business Name | JEANETTES SANCTUARY LLC
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Dates
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Enumeration Date | 03/20/2025
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 38780 CHESTNUT RIDGE RD
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City | ELYRIA
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State | OH
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Zip | 44035-8232
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Country | US
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Telephone | 440-219-4004
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Fax |
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Provider Business Mailing Address
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Address Line | 113 LEXINGTON AVE
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City | ELYRIA
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State | OH
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Zip | 44035-6217
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Country | US
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Telephone | 440-657-6446
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Fax |
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Authorized Official
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Title or Position | FOUNDER/CEO
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Name | MRS. LATASHA MONIQUE GORDON
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Credential | LPC, LICDC, OCPSA
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Telephone | 440-657-6446
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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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 |
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License Number State |
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