Provider Demographics
NPI:1679019731
Name:JEREMIAH'S INN INC.
Entity Type:Organization
Organization Name:JEREMIAH'S INN INC.
Other - Org Name:JEREMIAH'S HOSPICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COMMUNICATIONS COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-755-6403
Mailing Address - Street 1:1059 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-2421
Mailing Address - Country:US
Mailing Address - Phone:508-755-6403
Mailing Address - Fax:508-793-9568
Practice Address - Street 1:1059 MAIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2421
Practice Address - Country:US
Practice Address - Phone:508-755-6403
Practice Address - Fax:508-793-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0290324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility