MEDICARE: JUBILEE PERSONAL CARE HOME INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	033-01-160-1	GA

General Provider Information

NPI Number	:	1154644615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUBILEE PERSONAL CARE HOME INC.

Provider Business Mailing Address
First Line	:	3221 HOPKINS RD
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-3636
Country	:	US
Telephone Number	:	770-943-4214
Fax Number	:	770-943-4063

Provider Business Practice Location Address
First Line	:	3221 HOPKINS RD
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-3636
Country	:	US
Telephone Number	:	770-943-4214
Fax Number	:	770-943-4063

Authorized Official
Title or Position	:	CEO
Name	:	MS. JANE NWADIUTO OKEH
Credential	:
Telephone Number	:	404-538-8221

Provider Enumeration Date	:	03/11/2010
Last Update Date	:	03/11/2010

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