Provider Demographics
NPI:1508663923
Name:JESSIE MAE'S SUPPORTED LIVING, LLC
Entity type:Organization
Organization Name:JESSIE MAE'S SUPPORTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS-MACK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:757-967-1062
Mailing Address - Street 1:23069 RETREAT LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:VA
Mailing Address - Zip Code:23314-4192
Mailing Address - Country:US
Mailing Address - Phone:757-967-1062
Mailing Address - Fax:757-801-5375
Practice Address - Street 1:614 ROOSEVELT DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-3348
Practice Address - Country:US
Practice Address - Phone:757-967-1062
Practice Address - Fax:757-801-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances