Provider Demographics
NPI:1912278110
Name:JACKSON HOMECARE MINISTRIES 1
Entity Type:Organization
Organization Name:JACKSON HOMECARE MINISTRIES 1
Other - Org Name:JACKSON HOMECARE MINISTRIES 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:L V
Authorized Official - Middle Name:NONE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:C EO
Authorized Official - Phone:615-642-4665
Mailing Address - Street 1:310 RURAL HILL CT
Mailing Address - Street 2:B
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-3815
Mailing Address - Country:US
Mailing Address - Phone:615-642-4665
Mailing Address - Fax:615-367-5007
Practice Address - Street 1:321 RURAL HILL RD
Practice Address - Street 2:323 RURAL HILL RD
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37217-3834
Practice Address - Country:US
Practice Address - Phone:615-642-4665
Practice Address - Fax:615-367-5007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000012559;12560;261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNALYSSA44Medicaid