Provider Demographics
NPI:1710348370
Name:COVENANT PREMIUM SENIOR CARE
Entity Type:Organization
Organization Name:COVENANT PREMIUM SENIOR CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:281-394-9217
Mailing Address - Street 1:2918 CHAPEL ROCK
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-5256
Mailing Address - Country:US
Mailing Address - Phone:281-394-9217
Mailing Address - Fax:281-394-9216
Practice Address - Street 1:28307 SUGARSIDE GLEN DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-1480
Practice Address - Country:US
Practice Address - Phone:281-394-9217
Practice Address - Fax:281-394-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care