Healthcare Provider Details

I. General information

NPI: 1295092500
Provider Name (Legal Business Name): JAK PROPERTIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 M C BLACK RD
BONNE TERRE MO
63628-3649
US

IV. Provider business mailing address

400 M C BLACK RD
BONNE TERRE MO
63628-3649
US

V. Phone/Fax

Practice location:
  • Phone: 573-358-7755
  • Fax: 573-358-7788
Mailing address:
  • Phone: 573-358-7755
  • Fax: 573-358-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: AMY SUE PROFFER
Title or Position: PRESIDENT/CEO
Credential:
Phone: 573-358-7755