Provider Demographics
NPI:1861491466
Name:JACKSON MANOR 1691 TENANT, LLC
Entity Type:Organization
Organization Name:JACKSON MANOR 1691 TENANT, LLC
Other - Org Name:JACKSON MANOR NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:PALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-390-4363
Mailing Address - Street 1:1691 S HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-5856
Mailing Address - Country:US
Mailing Address - Phone:318-259-7386
Mailing Address - Fax:318-259-4644
Practice Address - Street 1:1691 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-5856
Practice Address - Country:US
Practice Address - Phone:318-259-7386
Practice Address - Fax:318-259-4644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA865314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1510726Medicaid
LA1510726Medicaid