Provider Demographics
NPI:1336755917
Name:LEAP OF FAITH ADULT SERVICES LLC
Entity Type:Organization
Organization Name:LEAP OF FAITH ADULT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/QDDP/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:WILLIAMS
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:804-605-7883
Mailing Address - Street 1:4409 TEAL CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-6882
Mailing Address - Country:US
Mailing Address - Phone:804-926-3744
Mailing Address - Fax:
Practice Address - Street 1:528 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5759
Practice Address - Country:US
Practice Address - Phone:804-605-7883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-19
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services