Provider Demographics
NPI:1578948055
Name:JACKSON HOME HEALTH
Entity Type:Organization
Organization Name:JACKSON HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHONTIA
Authorized Official - Middle Name:LATOYIA
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-789-4272
Mailing Address - Street 1:111 PECAN LAKE ESTATE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-9383
Mailing Address - Country:US
Mailing Address - Phone:318-789-4272
Mailing Address - Fax:
Practice Address - Street 1:111 PECAN LAKE ESTATE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-9383
Practice Address - Country:US
Practice Address - Phone:318-789-4272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities