Provider Demographics
NPI:1871779280
Name:JACKSON STYLE ADULT DAY CARE
Entity type:Organization
Organization Name:JACKSON STYLE ADULT DAY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEOTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-769-8565
Mailing Address - Street 1:12707 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-2207
Mailing Address - Country:US
Mailing Address - Phone:816-763-1078
Mailing Address - Fax:816-765-9987
Practice Address - Street 1:12707 2ND ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-2207
Practice Address - Country:US
Practice Address - Phone:816-763-1078
Practice Address - Fax:816-765-9987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON STYLE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO734320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities