Provider Demographics
NPI:1629208699
Name:JABEZ RESIDENTIAL INC
Entity Type:Organization
Organization Name:JABEZ RESIDENTIAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAMIEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:FORSYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-284-3723
Mailing Address - Street 1:PO BOX 1214
Mailing Address - Street 2:
Mailing Address - City:KENLY
Mailing Address - State:NC
Mailing Address - Zip Code:27542-1214
Mailing Address - Country:US
Mailing Address - Phone:919-284-3723
Mailing Address - Fax:
Practice Address - Street 1:212 TILGHMAN STREET
Practice Address - Street 2:
Practice Address - City:KENLY
Practice Address - State:NC
Practice Address - Zip Code:27542-1214
Practice Address - Country:US
Practice Address - Phone:919-284-3723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL051174320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities