MEDICARE: DIVINE HAVEN TRANSITIONAL LIVING 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1598608473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HAVEN TRANSITIONAL LIVING LLC

Provider Business Mailing Address
First Line	:	1811 N REYNOLDS RD STE 101
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-3533
Country	:	US
Telephone Number	:	567-277-2729
Fax Number	:

Provider Business Practice Location Address
First Line	:	1811 N REYNOLDS RD STE 101
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-3533
Country	:	US
Telephone Number	:	567-277-2729
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ CHIEF EXECUTIVE OFFICER
Name	:	JERRIKA JACKSON
Credential	:
Telephone Number	:	567-277-2729

Provider Enumeration Date	:	04/14/2026
Last Update Date	:	04/14/2026

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