Provider Demographics
NPI:1447877683
Name:JEREMY'S PLACE INC.
Entity type:Organization
Organization Name:JEREMY'S PLACE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATEISHA
Authorized Official - Middle Name:NICHOL
Authorized Official - Last Name:JACKSON-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-969-9334
Mailing Address - Street 1:4910 JONESBORO RD STE 201
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-2087
Mailing Address - Country:US
Mailing Address - Phone:770-969-9334
Mailing Address - Fax:770-969-9337
Practice Address - Street 1:4910 JONESBORO RD STE 201
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2087
Practice Address - Country:US
Practice Address - Phone:770-969-9334
Practice Address - Fax:770-969-9337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-04
Last Update Date:2020-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA604196354AMedicaid
GA003203627AMedicaid
GA003203627BMedicaid
GA604196354BMedicaid