MEDICARE: DIVINE GRACE ADULT FAMILY HOME LLC

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	311500000X	Alzheimer Center (Dementia Center)

General Provider Information

NPI Number	:	1235084740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE GRACE ADULT FAMILY HOME LLC

Provider Business Mailing Address
First Line	:	7727 W GLENDALE AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-5331
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7727 W GLENDALE AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-5331
Country	:	US
Telephone Number	:	414-274-9935
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MAURICE JACKSON SR
Credential	:
Telephone Number	:	414-379-3001

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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