Provider Demographics
NPI:1952980567
Name:JACKSON HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:JACKSON HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JE-JE
Authorized Official - Middle Name:W
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-428-3182
Mailing Address - Street 1:5604 ASHLEIGH PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-7821
Mailing Address - Country:US
Mailing Address - Phone:190-442-8318
Mailing Address - Fax:
Practice Address - Street 1:5604 ASHLEIGH PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-7821
Practice Address - Country:US
Practice Address - Phone:190-442-8318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013844800Medicaid