MEDICARE: BLACK JACK STAFFING

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1104564731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK JACK STAFFING

Provider Business Mailing Address
First Line	:	225 FAIRWAY BLVD
Second Line	:
City	:	WHITEHALL
State	:	OH
Zip	:	43213-2071
Country	:	US
Telephone Number	:	614-986-7185
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 FAIRWAY BLVD
Second Line	:
City	:	WHITEHALL
State	:	OH
Zip	:	43213-2071
Country	:	US
Telephone Number	:	614-986-7185
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. JACKIE DOODLEY JR.
Credential	:
Telephone Number	:	614-588-4436

Provider Enumeration Date	:	05/24/2022
Last Update Date	:	05/24/2022

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Directions to “BLACK JACK STAFFING ” Practice Location

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