Provider Demographics
NPI:1356937049
Name:JAYS LEGACY
Entity type:Organization
Organization Name:JAYS LEGACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:DERENNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-901-7780
Mailing Address - Street 1:283 BREEZY ACRES
Mailing Address - Street 2:
Mailing Address - City:LUXEMBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54217-9561
Mailing Address - Country:US
Mailing Address - Phone:920-901-7780
Mailing Address - Fax:
Practice Address - Street 1:283 BREEZY ACRES
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-9561
Practice Address - Country:US
Practice Address - Phone:920-901-7780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care