Provider Demographics
NPI:1255417432
Name:JACKSON LAKE HOSPICE INC
Entity type:Organization
Organization Name:JACKSON LAKE HOSPICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-305-9393
Mailing Address - Street 1:PO BOX 1927
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-0037
Mailing Address - Country:US
Mailing Address - Phone:770-305-9393
Mailing Address - Fax:770-305-9662
Practice Address - Street 1:128 BRANDON WAY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210
Practice Address - Country:US
Practice Address - Phone:770-305-9393
Practice Address - Fax:770-305-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based