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General NPI Number Information
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NPI Number | 1114528973
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Entity Type | Organization
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Legal Business Name | DAVIS JACKSON MEDICAL ASSIST TEAN LEE
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Dates
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Enumeration Date | 11/06/2020
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Last Update Date | 11/06/2020
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Provider Practice Location Address
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Address Line | 6449 IPTH DR.
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City | SAINT PAUL
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State | MN
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Zip | 55725-1130
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Country | US
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Telephone | 657-592-5960
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Fax | 651-286-2994
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Provider Business Mailing Address
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Address Line | 1321 E. 78TH STREET APT. 114
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City | BLOOMINGTON
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State | MN
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Zip | 55425-1114
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Country | US
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Telephone | 651-592-5960
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Fax | 651-286-2994
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MS. FLORENSE MONIQUE DAVIS
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Credential | CNA
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Telephone | 651-595-5960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 372500000X
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Taxonomy Name | Chore Provider
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State |
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