Provider Demographics
NPI:1831143478
Name:JAY-RANDOLPH DEVELOPMENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:JAY-RANDOLPH DEVELOPMENTAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-726-7931
Mailing Address - Street 1:901 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-2038
Mailing Address - Country:US
Mailing Address - Phone:260-726-7931
Mailing Address - Fax:260-726-8184
Practice Address - Street 1:901 E WATER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-2038
Practice Address - Country:US
Practice Address - Phone:260-726-7931
Practice Address - Fax:260-726-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2623I0005JN06315P00000X
IN2623I0004JN07315P00000X
IN2623B0006JN06315P00000X
IN2623T0003JN07315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities