Provider Demographics
NPI:1982148508
Name:JACKSON, JE-JE
Entity Type:Individual
Prefix:
First Name:JE-JE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:904-428-3182
Mailing Address - Fax:904-778-9707
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:904-428-3182
Practice Address - Fax:904-778-9707
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-16
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide
No376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider