Basic Information
| Provider Information | |||||||||
| NPI: | 1891303988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDING H.O.P.E. BY SRJ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3305 GOLDENROD ST | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294057866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438643679 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 CHARLIE HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294145832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438524100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2020 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | SONYA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8435572760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1760596480 | 05 | SC | MEDICAID |