Healthcare Provider Details

I. General information

NPI: 1437524709
Provider Name (Legal Business Name): JERRI'S PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 W 5TH ST
LAKELAND FL
33805-4316
US

IV. Provider business mailing address

PO BOX 90154
LAKELAND FL
33804-0154
US

V. Phone/Fax

Practice location:
  • Phone: 863-934-8028
  • Fax: 863-934-8028
Mailing address:
  • Phone: 863-687-6401
  • Fax: 863-687-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number9329
License Number StateFL

VIII. Authorized Official

Name: MS. JACQUELINE G. MCGORDON
Title or Position: ADM. / OWNER
Credential:
Phone: 863-934-8028