Provider Demographics
NPI:1689893836
Name:HOMEPLACE SUPPORT SERVICE, LLC
Entity Type:Organization
Organization Name:HOMEPLACE SUPPORT SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-936-2010
Mailing Address - Street 1:215 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1827
Mailing Address - Country:US
Mailing Address - Phone:859-936-2010
Mailing Address - Fax:859-936-2099
Practice Address - Street 1:215 S 4TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1827
Practice Address - Country:US
Practice Address - Phone:859-936-2010
Practice Address - Fax:859-936-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251B00000X251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY33001249Medicaid