Provider Demographics
NPI:1093850620
Name:JAG'S RESIDENTIAL SERVICES, LLC
Entity Type:Organization
Organization Name:JAG'S RESIDENTIAL SERVICES, LLC
Other - Org Name:JAG'S DEVELOPMENTAL DISABILITY ADULT CARE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER / DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:GOOLSBY
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-426-3752
Mailing Address - Street 1:1006 LAUREL LEAF RD
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597
Mailing Address - Country:US
Mailing Address - Phone:919-426-3752
Mailing Address - Fax:919-404-1515
Practice Address - Street 1:1005 LAUREL LEAF RD
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597
Practice Address - Country:US
Practice Address - Phone:919-426-3752
Practice Address - Fax:919-404-1515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
311Z00000X, 311ZA0620X
NCMHL-092-639320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805466Medicaid