Provider Demographics
NPI:1710788419
Name:JEANETTES SANCTUARY LLC
Entity type:Organization
Organization Name:JEANETTES SANCTUARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LICDC, OCPSA
Authorized Official - Phone:440-657-6446
Mailing Address - Street 1:113 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6217
Mailing Address - Country:US
Mailing Address - Phone:440-657-6446
Mailing Address - Fax:
Practice Address - Street 1:38780 CHESTNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-8232
Practice Address - Country:US
Practice Address - Phone:440-219-4004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty