Provider Demographics
NPI:1891864823
Name:SUPREME COUNCIL OF THE HOUSE OF JACOB OF THE USA INC
Entity Type:Organization
Organization Name:SUPREME COUNCIL OF THE HOUSE OF JACOB OF THE USA INC
Other - Org Name:JACOB'S DWELLING NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HULDAH
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHESNUT
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:740-824-3635
Mailing Address - Street 1:25680 TOWNSHIP RD. 39
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-9195
Mailing Address - Country:US
Mailing Address - Phone:740-824-3635
Mailing Address - Fax:740-824-5205
Practice Address - Street 1:25680 TOWNSHIP RD. 39
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-9195
Practice Address - Country:US
Practice Address - Phone:740-824-3635
Practice Address - Fax:740-824-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2436314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0280619Medicaid
OH0280619Medicaid