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General NPI Number Information
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NPI Number | 1437524709
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Entity Type | Organization
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Legal Business Name | JERRI'S PLACE, LLC
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Dates
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Enumeration Date | 12/11/2015
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Last Update Date | 12/11/2015
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Provider Practice Location Address
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Address Line | 624 W 5TH ST
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City | LAKELAND
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State | FL
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Zip | 33805-4316
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Country | US
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Telephone | 863-934-8028
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Fax | 863-934-8028
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Provider Business Mailing Address
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Address Line | PO BOX 90154
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City | LAKELAND
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State | FL
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Zip | 33804-0154
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Country | US
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Telephone | 863-687-6401
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Fax | 863-687-6401
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Authorized Official
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Title or Position | ADM. / OWNER
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Name | MS. JACQUELINE G. MCGORDON
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Credential |
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Telephone | 863-934-8028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | 9329
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License Number State | FL
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