Provider Demographics
NPI:1205370228
Name:JACKIE'S ANGEL LLC
Entity Type:Organization
Organization Name:JACKIE'S ANGEL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LASHONDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-736-1180
Mailing Address - Street 1:185 CAPRI DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5808
Mailing Address - Country:US
Mailing Address - Phone:314-736-1180
Mailing Address - Fax:
Practice Address - Street 1:185 CAPRI DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5808
Practice Address - Country:US
Practice Address - Phone:314-736-1180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health