MEDICARE: JACKSON CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1083163398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON CARE LLC

Provider Business Mailing Address
First Line	:	342 N WATER ST
Second Line	:	SUITE 600
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-5514
Country	:	US
Telephone Number	:	214-552-4493
Fax Number	:

Provider Business Practice Location Address
First Line	:	342 N WATER ST
Second Line	:	SUITE 600
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-5514
Country	:	US
Telephone Number	:	214-552-4493
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	ACELIA JACKSON
Credential	:
Telephone Number	:	214-552-4493

Provider Enumeration Date	:	09/27/2016
Last Update Date	:	09/27/2016

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