Provider Demographics
NPI:1467575357
Name:JACKSON'S GROUP HOME
Entity Type:Organization
Organization Name:JACKSON'S GROUP HOME
Other - Org Name:PERSONAL TOUCH
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EARNESTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-688-2228
Mailing Address - Street 1:7570 US HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-9183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:537-688-5174
Practice Address - Street 1:7570 US HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869-9183
Practice Address - Country:US
Practice Address - Phone:573-688-2228
Practice Address - Fax:537-688-5174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities