Provider Demographics
NPI:1164640363
Name:JACKSBORO ASSISTED LIVING, INC.
Entity Type:Organization
Organization Name:JACKSBORO ASSISTED LIVING, INC.
Other - Org Name:GREYSTONE PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:JEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-622-6300
Mailing Address - Street 1:1116 US HIGHWAY 148
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76458-3439
Mailing Address - Country:US
Mailing Address - Phone:940-567-3057
Mailing Address - Fax:940-567-5782
Practice Address - Street 1:1116 US HIGHWAY 148
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TX
Practice Address - Zip Code:76458-3439
Practice Address - Country:US
Practice Address - Phone:940-567-3057
Practice Address - Fax:940-567-5782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120111310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility