1467721829 NPI number — CLISSIE TERERSA JACKSON HOME CARE

Table of content: CLISSIE TERERSA JACKSON HOME CARE (NPI 1467721829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467721829 NPI number — CLISSIE TERERSA JACKSON HOME CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
CLISSIE
Provider Middle Name:
TERERSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HOME CARE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467721829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 74TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35206-4261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-358-0035
Provider Business Mailing Address Fax Number:
186-665-9907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 74TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35206-4261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-358-0035
Provider Business Practice Location Address Fax Number:
186-665-9907
Provider Enumeration Date:
12/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 376K00000X , with the licence number:  119405B , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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