Provider Demographics
NPI:1467742858
Name:G.R. JACKSON SENIOR CARE
Entity Type:Organization
Organization Name:G.R. JACKSON SENIOR CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ORTEASA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:TAFIE
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:404-274-4498
Mailing Address - Street 1:1325 SIX FLAGS DR
Mailing Address - Street 2:#1207
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-7065
Mailing Address - Country:US
Mailing Address - Phone:404-274-4498
Mailing Address - Fax:678-324-6791
Practice Address - Street 1:1325 SIX FLAGS DR
Practice Address - Street 2:#1207
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-7065
Practice Address - Country:US
Practice Address - Phone:404-274-4498
Practice Address - Fax:678-324-6791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0028902879251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health