Provider Demographics
NPI:1386701613
Name:JACKSON STYLE AGENCY, LLC
Entity type:Organization
Organization Name:JACKSON STYLE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
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:816-765-9990
Mailing Address - Street 1:213 BLUE RIDGE EXT
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-1603
Mailing Address - Country:US
Mailing Address - Phone:816-765-9990
Mailing Address - Fax:816-765-9987
Practice Address - Street 1:213 BLUE RIDGE EXT
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-1603
Practice Address - Country:US
Practice Address - Phone:816-765-9990
Practice Address - Fax:816-765-9987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities