Provider Demographics
NPI:1053308841
Name:JACKSBORO HEALTH CARE CENTER
Entity Type:Organization
Organization Name:JACKSBORO HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LVN
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:UPTERGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-567-2686
Mailing Address - Street 1:211 E JASPER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76458-1848
Mailing Address - Country:US
Mailing Address - Phone:940-567-2686
Mailing Address - Fax:940-567-5038
Practice Address - Street 1:211 E JASPER ST
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TX
Practice Address - Zip Code:76458-1848
Practice Address - Country:US
Practice Address - Phone:940-567-2686
Practice Address - Fax:940-567-5038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4888310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX436209130C1Medicare ID - Type Unspecified