Healthcare Provider Details

I. General information

NPI: 1902250012
Provider Name (Legal Business Name): JACKSON MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 HIGHWAY 3444
ANNVILLE KY
40402-8245
US

IV. Provider business mailing address

700 N HURSTBOURNE PKWY
LOUISVILLE KY
40222-5393
US

V. Phone/Fax

Practice location:
  • Phone: 502-714-7444
  • Fax:
Mailing address:
  • Phone: 502-714-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROBIN BARBER
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 502-714-7444