Provider Demographics
NPI:1538128095
Name:JACKSON HEALTH CARE FACILITY, LLC
Entity Type:Organization
Organization Name:JACKSON HEALTH CARE FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-743-7137
Mailing Address - Street 1:501 WHETSTONE ST
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36460-2615
Mailing Address - Country:US
Mailing Address - Phone:251-743-3609
Mailing Address - Fax:251-575-5618
Practice Address - Street 1:2616 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-2469
Practice Address - Country:US
Practice Address - Phone:251-246-2476
Practice Address - Fax:251-246-2437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12499313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4753010SMedicaid
01-5188Medicare ID - Type Unspecified