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General NPI Number Information
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NPI Number | 1467742858
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Entity Type | Organization
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Legal Business Name | G.R. JACKSON SENIOR CARE
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Dates
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Enumeration Date | 04/19/2011
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Last Update Date | 04/19/2011
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Provider Practice Location Address
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Address Line | 1325 SIX FLAGS DR #1207
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City | AUSTELL
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State | GA
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Zip | 30168-7065
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Country | US
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Telephone | 404-274-4498
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Fax | 678-324-6791
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Provider Business Mailing Address
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Address Line | 1325 SIX FLAGS DR #1207
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City | AUSTELL
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State | GA
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Zip | 30168-7065
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Country | US
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Telephone | 404-274-4498
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Fax | 678-324-6791
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Authorized Official
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Title or Position | OWNER
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Name | MRS. ORTEASA MARIA TAFIE
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Credential | CNA
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Telephone | 404-274-4498
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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 | CN0028902879
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License Number State | GA
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