Provider Demographics
NPI:1215393269
Name:J DIVINE, LLC
Entity Type:Organization
Organization Name:J DIVINE, LLC
Other - Org Name:DIVINE HOME HEALTH AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-207-5272
Mailing Address - Street 1:5743 FARWELL DR.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-5501
Mailing Address - Country:US
Mailing Address - Phone:832-207-5272
Mailing Address - Fax:713-485-0804
Practice Address - Street 1:5743 FARWELL DR.
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-5501
Practice Address - Country:US
Practice Address - Phone:832-207-5272
Practice Address - Fax:713-485-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty