Provider Demographics
NPI:1346449105
Name:JACKSON STYLE GROUP HOME
Entity Type:Organization
Organization Name:JACKSON STYLE GROUP HOME
Other - Org Name:JACKSON STYLE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST. ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEOTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-765-9990
Mailing Address - Street 1:213 BLUE RIDGE EXT
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-1604
Mailing Address - Country:US
Mailing Address - Phone:816-765-9990
Mailing Address - Fax:816-765-9987
Practice Address - Street 1:11815 BEACON AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64134-3708
Practice Address - Country:US
Practice Address - Phone:816-763-8335
Practice Address - Fax:816-765-9987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities