Healthcare Provider Details

I. General information

NPI: 1073814893
Provider Name (Legal Business Name): JACKSON SENIOR SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 CHEYENNE DR
JACKSON TN
38305-5412
US

IV. Provider business mailing address

420 CHEYENNE DR
JACKSON TN
38305-5412
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-9888
  • Fax: 731-661-9056
Mailing address:
  • Phone: 731-661-9888
  • Fax: 731-661-9056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberACL0000000124
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberACL0000000124
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberACL0000000124
License Number StateTN

VIII. Authorized Official

Name: MR. MATTHEW A ERNST
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 731-661-9888