Healthcare Provider Details

I. General information

NPI: 1922437318
Provider Name (Legal Business Name): JACKSON FALLS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5611 WILDERNESS TRCE
STONE MTN GA
30087-5266
US

IV. Provider business mailing address

5611 WILDERNESS TRCE
STONE MTN GA
30087-5266
US

V. Phone/Fax

Practice location:
  • Phone: 404-803-3805
  • Fax:
Mailing address:
  • Phone: 404-803-3805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number044018521
License Number StateGA

VIII. Authorized Official

Name: CELIA JACKSON
Title or Position: CEO
Credential:
Phone: 404-803-3805