MEDICARE: JACKSON FALLS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	044018521	GA

General Provider Information

NPI Number	:	1922437318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON FALLS INC

Provider Business Mailing Address
First Line	:	5611 WILDERNESS TRCE
Second Line	:
City	:	STONE MTN
State	:	GA
Zip	:	30087-5266
Country	:	US
Telephone Number	:	404-803-3805
Fax Number	:

Provider Business Practice Location Address
First Line	:	5611 WILDERNESS TRCE
Second Line	:
City	:	STONE MTN
State	:	GA
Zip	:	30087-5266
Country	:	US
Telephone Number	:	404-803-3805
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CELIA JACKSON
Credential	:
Telephone Number	:	404-803-3805

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	11/05/2013

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