Provider Demographics
NPI:1366153454
Name:JEREMIAH RECOVERY HOUSE, INC.
Entity type:Organization
Organization Name:JEREMIAH RECOVERY HOUSE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-716-9365
Mailing Address - Street 1:801 W TRIMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-5101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:706 PARK ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-3134
Practice Address - Country:US
Practice Address - Phone:870-661-2099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-08
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder