Provider Demographics
NPI:1942328695
Name:JEANS REST HOME
Entity Type:Organization
Organization Name:JEANS REST HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:LULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-480-0020
Mailing Address - Street 1:114 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-3440
Mailing Address - Country:US
Mailing Address - Phone:910-480-0020
Mailing Address - Fax:910-480-0020
Practice Address - Street 1:114 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3440
Practice Address - Country:US
Practice Address - Phone:910-480-0020
Practice Address - Fax:910-480-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL026029261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802336Medicaid