Jag's Residential Services, LLC

Primary specialty

Adult Care Home FacilityTaxonomy code 311ZA0620X

Legal business name

JAG'S RESIDENTIAL SERVICES, LLC

Practice address

1005 Laurel Leaf Rd
Zebulon, NC 27597

Phone

(919) 426-3752

Fax

(919) 404-1515

NPI assigned

Feb 21, 2007

Last updated

Sep 8, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Gwendolyn Goolsby Johns

Title

Owner / Director

Phone

(919) 426-3752

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• JAG'S Developmental Disability Adult Care, LLC Former legal business name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631059200000",
    "number": "1093850620",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1006 LAUREL LEAF RD",
            "city": "ZEBULON",
            "state": "NC",
            "postal_code": "27597",
            "telephone_number": "919-426-3752",
            "fax_number": "919-404-1515"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1005 LAUREL LEAF RD",
            "city": "ZEBULON",
            "state": "NC",
            "postal_code": "27597",
            "telephone_number": "919-426-3752",
            "fax_number": "919-404-1515"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JAG'S RESIDENTIAL SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-21",
        "last_updated": "2021-09-08",
        "certification_date": "2021-09-08",
        "status": "A",
        "authorized_official_last_name": "JOHNS",
        "authorized_official_first_name": "GWENDOLYN",
        "authorized_official_middle_name": "GOOLSBY",
        "authorized_official_title_or_position": "OWNER / DIRECTOR",
        "authorized_official_telephone_number": "919-426-3752",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "311Z00000X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "311ZA0620X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility, Adult Care Home",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": "NC",
            "license": "MHL-092-639",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7805466",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "JAG'S Developmental Disability Adult Care, LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• Adult Care Home Facility in Zebulon, NC
• Providers in Zebulon, NC by specialty
• Adult Care Home Facility in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.