Healthcare Provider Details

I. General information

NPI: 1104323070
Provider Name (Legal Business Name): GOLDEN YEARS ADULT DAYCARE OF JACKSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 03/12/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 WHITEHALL STREET
JACKSON TN
38301-3730
US

IV. Provider business mailing address

155 CARRIAGE DR SUITE A
JACKSON TN
38305
US

V. Phone/Fax

Practice location:
  • Phone: 731-736-2440
  • Fax: 731-736-3655
Mailing address:
  • Phone: 731-506-9068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateTN

VIII. Authorized Official

Name: BRENDA F DOUGLAS
Title or Position: MANGER
Credential:
Phone: 731-267-0818