Provider Demographics
NPI:1437524709
Name:JERRI'S PLACE, LLC
Entity Type:Organization
Organization Name:JERRI'S PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM. / OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCGORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-934-8028
Mailing Address - Street 1:PO BOX 90154
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-0154
Mailing Address - Country:US
Mailing Address - Phone:863-687-6401
Mailing Address - Fax:863-687-6401
Practice Address - Street 1:624 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4316
Practice Address - Country:US
Practice Address - Phone:863-934-8028
Practice Address - Fax:863-934-8028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9329261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care