Provider Demographics
NPI:1992890099
Name:JACKSON PLAZA INC
Entity type:Organization
Organization Name:JACKSON PLAZA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:ESCOBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-347-3380
Mailing Address - Street 1:1861 NW 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1115
Mailing Address - Country:US
Mailing Address - Phone:305-347-3380
Mailing Address - Fax:305-347-3388
Practice Address - Street 1:1861 NW 8TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1115
Practice Address - Country:US
Practice Address - Phone:305-347-3380
Practice Address - Fax:305-347-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1255096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025372300Medicaid
FL025372300Medicaid