Provider Demographics
NPI:1619612876
Name:JEHOVAHS BEHAVIORAL CARE LLC
Entity Type:Organization
Organization Name:JEHOVAHS BEHAVIORAL CARE LLC
Other - Org Name:GRACE FOMUNUNG SOLE MBR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOMUNUNG
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:404-819-7338
Mailing Address - Street 1:4652 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3621
Mailing Address - Country:US
Mailing Address - Phone:404-819-7338
Mailing Address - Fax:
Practice Address - Street 1:3206 THIMBLEBERRY TRL
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7299
Practice Address - Country:US
Practice Address - Phone:404-819-7338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health