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General NPI Number Information
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NPI Number | 1912333618
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Entity Type | Organization
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Legal Business Name | JENNY'S PLACE
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Dates
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Enumeration Date | 09/25/2013
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Last Update Date | 09/25/2013
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Provider Practice Location Address
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Address Line | 661 ERLWOOD PATH
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City | BERRIEN SPRINGS
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State | MI
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Zip | 49103-1672
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Country | US
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Telephone | 269-471-3761
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Fax | 269-815-5089
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Provider Business Mailing Address
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Address Line | 661 ERLWOOD PATH
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City | BERRIEN SPRINGS
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State | MI
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Zip | 49103-1672
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Country | US
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Telephone | 269-471-3761
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Fax | 269-815-5089
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Authorized Official
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Title or Position | CO-OWNER, MANAGER
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Name | MR. RAMLEN KAUMPUNGAN
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Credential |
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Telephone | 269-277-1353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | AF110088792
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License Number State | MI
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