Healthcare Provider Details

I. General information

NPI: 1972756054
Provider Name (Legal Business Name): JAC NURSING REGISTRY INTERNATIONAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 HUGH HOWELL RD 320
TUCKER GA
30084-4723
US

IV. Provider business mailing address

7078 BILTMORE TRCE
LITHONIA GA
30058-2962
US

V. Phone/Fax

Practice location:
  • Phone: 770-753-9070
  • Fax: 770-621-9433
Mailing address:
  • Phone: 770-753-9070
  • Fax: 770-621-9433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number041157362
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number041157362
License Number StateGA

VIII. Authorized Official

Name: MS. CHRIS MOODY
Title or Position: PRACRICE MANAGER
Credential: CBCS
Phone: 678-705-2633