Provider Demographics
NPI:1700502630
Name:DIVINE ESSENCE ABUNDANCE HOME CARE SERVICES LLC
Entity Type:Organization
Organization Name:DIVINE ESSENCE ABUNDANCE HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY OWNER/ DIRECTOR OF OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:JERRIKA
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-277-2729
Mailing Address - Street 1:1811 NORTH REYNOLDS UNIT 101-A
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615
Mailing Address - Country:US
Mailing Address - Phone:567-277-2729
Mailing Address - Fax:
Practice Address - Street 1:1811 NORTH REYNOLDS UNIT 101-A
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615
Practice Address - Country:US
Practice Address - Phone:567-277-2729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0484848Medicaid