Provider Demographics
NPI:1407508948
Name:DEVILLE, JAY E (OWNER)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:E
Last Name:DEVILLE
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 JOHN DAVENPORT DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2509
Mailing Address - Country:US
Mailing Address - Phone:706-290-7701
Mailing Address - Fax:706-290-7702
Practice Address - Street 1:11 JOHN DAVENPORT DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2509
Practice Address - Country:US
Practice Address - Phone:706-290-7701
Practice Address - Fax:706-290-7702
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057-R-0017251E00000X, 374U00000X
GA057R0017253Z00000X
GA057-R00-17253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1770031478Medicaid