Provider Demographics
NPI:1922204619
Name:JACKIE R WHITE
Entity Type:Organization
Organization Name:JACKIE R WHITE
Other - Org Name:WHITE FAMILY ISL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-673-6139
Mailing Address - Street 1:730 NE 25TH ST
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:MO
Mailing Address - Zip Code:64641-9153
Mailing Address - Country:US
Mailing Address - Phone:660-673-6139
Mailing Address - Fax:
Practice Address - Street 1:730 NE 25TH ST
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:MO
Practice Address - Zip Code:64641-9153
Practice Address - Country:US
Practice Address - Phone:660-673-6139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities