Healthcare Provider Details

I. General information

NPI: 1992006365
Provider Name (Legal Business Name): JACKSON'S PERSONAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2377 DUBLIN DR
AUGUSTA GA
30906-4020
US

IV. Provider business mailing address

2377 DUBLIN DR
AUGUSTA GA
30906-4020
US

V. Phone/Fax

Practice location:
  • Phone: 706-798-2127
  • Fax: 706-496-7305
Mailing address:
  • Phone: 706-798-2127
  • Fax: 706-496-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number121013781
License Number StateGA

VIII. Authorized Official

Name: MRS. VELMA L JACKSON
Title or Position: OWNER
Credential:
Phone: 706-793-6487