Healthcare Provider Details

I. General information

NPI: 1982148508
Provider Name (Legal Business Name): JE-JE JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 ASHLEIGH PARK DR
JACKSONVILLE FL
32244-7821
US

IV. Provider business mailing address

5604 ASHLEIGH PARK DR
JACKSONVILLE FL
32244-7821
US

V. Phone/Fax

Practice location:
  • Phone: 904-428-3182
  • Fax: 904-778-9707
Mailing address:
  • Phone: 904-428-3182
  • Fax: 904-778-9707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: