| Organization Name: | JASPER DIVISION |
| NPI Number: | 1912159377 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | PARLUHUTAN WAHAB SIREGAR (QMRP/ADMINISTRATOR) |
| Mailing Address: | 9140 Monte Vista Ave Montclair |
| State: | CA US |
| Postal Code: | 917631723 |
| Phone Number: | 9096242774 |
| Fax Number: | 9096246014 |
| NPI Enumeration Date: | 10/16/2008 |
| NPI Last Update Date: | 10/16/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320900000X |
| License Number: | 240000824 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |