Provider Demographics
NPI:1588946370
Name:JACKSON GROUP HOME LLC
Entity type:Organization
Organization Name:JACKSON GROUP HOME LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CULP
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN
Authorized Official - Phone:573-221-4671
Mailing Address - Street 1:18 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-3056
Mailing Address - Country:US
Mailing Address - Phone:573-221-4671
Mailing Address - Fax:573-221-4671
Practice Address - Street 1:18 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-3056
Practice Address - Country:US
Practice Address - Phone:573-221-4671
Practice Address - Fax:573-221-4671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-16
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2500-12463320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities