Provider Demographics
NPI:1265601223
Name:MRS. JENNIE'S PLACE COMMUNITY ENRICHMENT CENTER
Entity type:Organization
Organization Name:MRS. JENNIE'S PLACE COMMUNITY ENRICHMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:VALERIA
Authorized Official - Middle Name:H
Authorized Official - Last Name:SUMPTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-765-5748
Mailing Address - Street 1:506 RAVENSTONE LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-9621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 COX AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-4519
Practice Address - Country:US
Practice Address - Phone:919-765-5748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-425320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities