Provider Demographics
NPI:1104328012
Name:JAKES PLACE FOR CHANGE, LLC
Entity type:Organization
Organization Name:JAKES PLACE FOR CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MS COUNSELING, LBSW
Authorized Official - Phone:256-459-5600
Mailing Address - Street 1:116 CHURCH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:RAINBOW CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35906-6287
Mailing Address - Country:US
Mailing Address - Phone:256-459-5600
Mailing Address - Fax:
Practice Address - Street 1:116 CHURCH ST STE 4
Practice Address - Street 2:
Practice Address - City:RAINBOW CITY
Practice Address - State:AL
Practice Address - Zip Code:35906-6287
Practice Address - Country:US
Practice Address - Phone:256-459-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No253Z00000XAgenciesIn Home Supportive Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch
No347C00000XTransportation ServicesPrivate Vehicle
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child