Provider Demographics
NPI:1548319247
Name:JOHN & JENNERINE ENTERPRISE, INC.
Entity type:Organization
Organization Name:JOHN & JENNERINE ENTERPRISE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/EFT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-342-2609
Mailing Address - Street 1:PO BOX 1583
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323-1583
Mailing Address - Country:US
Mailing Address - Phone:336-342-2609
Mailing Address - Fax:336-342-6362
Practice Address - Street 1:3008 NC HIGHWAY 150
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-8112
Practice Address - Country:US
Practice Address - Phone:336-342-2609
Practice Address - Fax:336-342-6362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-079-058320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities