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General NPI Number Information
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NPI Number | 1164199410
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Entity Type | Organization
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Legal Business Name | JACKSON SUPPORT SERVICES
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Dates
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Enumeration Date | 08/25/2021
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Last Update Date | 09/30/2021
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Provider Practice Location Address
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Address Line | 532 BUCKINGHAM PL
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City | DESOTO
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State | TX
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Zip | 75115-6111
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Country | US
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Telephone | 619-846-5650
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Fax | 619-846-5659
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Provider Business Mailing Address
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Address Line | 532 BUCKINGHAM PL
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City | DESOTO
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State | TX
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Zip | 75115-6111
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Country | US
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Telephone | 619-845-5650
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LATASHA JACKSON
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Credential |
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Telephone | 619-846-5650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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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 | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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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 | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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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 | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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