Provider Demographics
NPI:1205834413
Name:JACARANDA MANOR
Entity Type:Organization
Organization Name:JACARANDA MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:727-546-2405
Mailing Address - Street 1:4250 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:KENNETH CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33709-4918
Mailing Address - Country:US
Mailing Address - Phone:727-546-2405
Mailing Address - Fax:727-541-5154
Practice Address - Street 1:4250 66TH ST N
Practice Address - Street 2:
Practice Address - City:KENNETH CITY
Practice Address - State:FL
Practice Address - Zip Code:33709-4918
Practice Address - Country:US
Practice Address - Phone:727-546-2405
Practice Address - Fax:727-541-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1252096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSNF1252096OtherLICENSE NUMBER