Healthcare Provider Details

I. General information

NPI: 1861491466
Provider Name (Legal Business Name): JACKSON MANOR 1691 TENANT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 S HUDSON AVE
JONESBORO LA
71251-5856
US

IV. Provider business mailing address

1691 S HUDSON AVE
JONESBORO LA
71251-5856
US

V. Phone/Fax

Practice location:
  • Phone: 318-259-7386
  • Fax: 318-259-4644
Mailing address:
  • Phone: 318-259-7386
  • Fax: 318-259-4644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number865
License Number StateLA

VIII. Authorized Official

Name: MR. ALEX PALEY
Title or Position: COO
Credential:
Phone: 914-390-4363