Provider Demographics
NPI:1861842296
Name:JACKSON CENTER FOR INDEPENDENT LIVING
Entity Type:Organization
Organization Name:JACKSON CENTER FOR INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-668-2211
Mailing Address - Street 1:1981 HOLLYWOOD DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4368
Mailing Address - Country:US
Mailing Address - Phone:731-668-2211
Mailing Address - Fax:731-668-0406
Practice Address - Street 1:1981 HOLLYWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-4368
Practice Address - Country:US
Practice Address - Phone:731-668-2211
Practice Address - Fax:731-668-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ021666Medicaid