Provider Demographics
NPI:1972756054
Name:JAC NURSING REGISTRY INTERNATIONAL INC
Entity type:Organization
Organization Name:JAC NURSING REGISTRY INTERNATIONAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACRICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:CBCS
Authorized Official - Phone:678-705-2633
Mailing Address - Street 1:7078 BILTMORE TRCE
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-2962
Mailing Address - Country:US
Mailing Address - Phone:770-753-9070
Mailing Address - Fax:770-621-9433
Practice Address - Street 1:4500 HUGH HOWELL RD
Practice Address - Street 2:320
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4723
Practice Address - Country:US
Practice Address - Phone:770-753-9070
Practice Address - Fax:770-621-9433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041157362311ZA0620X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care HomeGroup - Single Specialty
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherLICENSE NURSE