Provider Demographics
NPI:1689664765
Name:CLC OF JACKSON, LLC
Entity Type:Organization
Organization Name:CLC OF JACKSON, LLC
Other - Org Name:PLEASANT HILLS COMMUNITY LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-680-3148
Mailing Address - Street 1:1600 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-4203
Mailing Address - Country:US
Mailing Address - Phone:601-371-1700
Mailing Address - Fax:601-371-1006
Practice Address - Street 1:1600 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4203
Practice Address - Country:US
Practice Address - Phone:601-371-1700
Practice Address - Fax:601-371-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS612314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0230178Medicaid
MS0230178Medicaid