Provider Demographics
NPI:1790237170
Name:JERUSALEM OUTREACH CENTER, INC
Entity Type:Organization
Organization Name:JERUSALEM OUTREACH CENTER, INC
Other - Org Name:JERUSALEM LIFE ADJUSTMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BESSIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-625-6788
Mailing Address - Street 1:710 MARSHALL ST
Mailing Address - Street 2:P.O. BOX 405
Mailing Address - City:CHARLESTON
Mailing Address - State:MS
Mailing Address - Zip Code:38921-9506
Mailing Address - Country:US
Mailing Address - Phone:662-625-6788
Mailing Address - Fax:662-625-6787
Practice Address - Street 1:710 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921-9506
Practice Address - Country:US
Practice Address - Phone:662-625-6788
Practice Address - Fax:662-625-6787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child