Provider Demographics
NPI:1073882783
Name:JACKIES RETIREMENT LLC
Entity Type:Organization
Organization Name:JACKIES RETIREMENT LLC
Other - Org Name:JACKIES RETIREMENT ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-420-3916
Mailing Address - Street 1:1675 CANON AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-8528
Mailing Address - Country:US
Mailing Address - Phone:321-420-3916
Mailing Address - Fax:
Practice Address - Street 1:1675 CANON AVE NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-8528
Practice Address - Country:US
Practice Address - Phone:321-420-3916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12053302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization