Provider Demographics
NPI:1194985739
Name:J & J ASSISTIVE LIVING
Entity type:Organization
Organization Name:J & J ASSISTIVE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-238-4602
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764-0378
Mailing Address - Country:US
Mailing Address - Phone:573-238-4602
Mailing Address - Fax:573-238-3233
Practice Address - Street 1:104 WESBECHER
Practice Address - Street 2:
Practice Address - City:MARBLE
Practice Address - State:MO
Practice Address - Zip Code:63764
Practice Address - Country:US
Practice Address - Phone:573-238-1008
Practice Address - Fax:573-238-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO034164320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM268918505Medicaid