Provider Demographics
NPI:1396157681
Name:JACK 1 FOUNDATION INC.
Entity type:Organization
Organization Name:JACK 1 FOUNDATION INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDYETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-719-7003
Mailing Address - Street 1:235 PROCTER ST.
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640
Mailing Address - Country:US
Mailing Address - Phone:409-984-5720
Mailing Address - Fax:409-984-5720
Practice Address - Street 1:235 PROCTER ST.
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640
Practice Address - Country:US
Practice Address - Phone:409-984-5720
Practice Address - Fax:409-984-5720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385H00000XRespite Care FacilityRespite Care