Provider Demographics
NPI:1407845639
Name:NEW JACKSON MANOR, LLC
Entity Type:Organization
Organization Name:NEW JACKSON MANOR, LLC
Other - Org Name:ANNVILLE ADULT DAY HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:502-753-6004
Mailing Address - Street 1:9510 ORMSBY STATION ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223
Mailing Address - Country:US
Mailing Address - Phone:502-753-6004
Mailing Address - Fax:502-753-6104
Practice Address - Street 1:68 HWY 3444
Practice Address - Street 2:
Practice Address - City:ANNVILLE
Practice Address - State:KY
Practice Address - Zip Code:40402
Practice Address - Country:US
Practice Address - Phone:606-364-5197
Practice Address - Fax:606-364-2293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
KY750066261QA0600X
KY100602314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100174140Medicaid