Provider Demographics
NPI:1225158371
Name:DEVELOPMENTAL ENRICHMENT SERVICES, INC.
Entity Type:Organization
Organization Name:DEVELOPMENTAL ENRICHMENT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:V
Authorized Official - Last Name:JACCINO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:770-879-0817
Mailing Address - Street 1:3615 S ROCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4408
Mailing Address - Country:US
Mailing Address - Phone:770-879-0817
Mailing Address - Fax:
Practice Address - Street 1:3615 S ROCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-4408
Practice Address - Country:US
Practice Address - Phone:770-879-0817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00016261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00599035Medicaid