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General NPI Number Information
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NPI Number | 1831143478
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Entity Type | Organization
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Legal Business Name | JAY-RANDOLPH DEVELOPMENTAL SERVICES, INC.
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Dates
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Enumeration Date | 05/19/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 901 E WATER ST
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City | PORTLAND
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State | IN
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Zip | 47371-2038
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Country | US
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Telephone | 260-726-7931
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Fax | 260-726-8184
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Provider Business Mailing Address
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Address Line | 901 E WATER ST
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City | PORTLAND
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State | IN
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Zip | 47371-2038
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Country | US
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Telephone | 260-726-7931
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Fax | 260-726-8184
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ANITA YOUNG
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Credential |
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Telephone | 260-726-7931
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 2623I0004JN07
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 2623B0006JN06
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 2623T0003JN07
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 2623I0005JN06
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License Number State | IN
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