Healthcare Provider Details

I. General information

NPI: 1467051631
Provider Name (Legal Business Name): JACKSON HOME FOR VETERANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 JUNIPER DR
CHARLOTTE NC
28269-4004
US

IV. Provider business mailing address

2633 JUNIPER DR
CHARLOTTE NC
28269-4004
US

V. Phone/Fax

Practice location:
  • Phone: 704-315-7089
  • Fax:
Mailing address:
  • Phone: 704-315-7089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1000X
TaxonomyMigrant Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: LEVAR LAFAYETTE JACKSON
Title or Position: OWNER
Credential:
Phone: 704-315-7089