MEDICARE: JONATHAN'S HAVEN 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1437086436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONATHAN'S HAVEN LLC

Provider Business Mailing Address
First Line	:	PO BOX 354
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-0354
Country	:	US
Telephone Number	:	973-873-8887
Fax Number	:	973-228-7068

Provider Business Practice Location Address
First Line	:	167-169 DICKERSON ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07107-3222
Country	:	US
Telephone Number	:	973-873-8887
Fax Number	:	973-228-7068

Authorized Official
Title or Position	:	PRESIDENT, CEO
Name	:	GWENDOLYN MONANGAI
Credential	:
Telephone Number	:	973-652-4541

Provider Enumeration Date	:	05/05/2026
Last Update Date	:	05/05/2026

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