Healthcare Provider Details

I. General information

NPI: 1992890099
Provider Name (Legal Business Name): JACKSON PLAZA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1861 NW 8TH AVE
MIAMI FL
33136-1115
US

IV. Provider business mailing address

1861 NW 8TH AVE
MIAMI FL
33136-1115
US

V. Phone/Fax

Practice location:
  • Phone: 305-347-3380
  • Fax: 305-347-3388
Mailing address:
  • Phone: 305-347-3380
  • Fax: 305-347-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1255096
License Number StateFL

VIII. Authorized Official

Name: MS. TERRY G ESCOBAR
Title or Position: ADMINISTRATOR
Credential:
Phone: 305-347-3380