Provider Demographics
NPI:1184315012
Name:JADEM ARK OF HOPE, LLC
Entity type:Organization
Organization Name:JADEM ARK OF HOPE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ORGANIZATION
Authorized Official - Prefix:
Authorized Official - First Name:MERCY
Authorized Official - Middle Name:NKENGAWUNG
Authorized Official - Last Name:NKEZE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:206-334-3511
Mailing Address - Street 1:10370 W ODEUM LN
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-4194
Mailing Address - Country:US
Mailing Address - Phone:206-334-3511
Mailing Address - Fax:
Practice Address - Street 1:1214 E FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-3938
Practice Address - Country:US
Practice Address - Phone:480-284-5590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ131381Medicaid