Jackson Group Home LLC

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

License

2500-12463 Issued in MO

Legal business name

JACKSON GROUP HOME LLC

Practice address

18 Ridgewood Dr
Hannibal, MO 63401-3056

Phone

(573) 221-4671

Fax

(573) 221-4671

NPI assigned

Sep 16, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Lora L Culp, BSN, RN

Title

Owner/Operator

Phone

(573) 221-4671

Specialties & licenses 1

Addresses

Other names 1

• Jackson Group Home Former legal business name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1316131200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1491696000000",
    "number": "1588946370",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18 RIDGEWOOD DR",
            "city": "HANNIBAL",
            "state": "MO",
            "postal_code": "634013056",
            "telephone_number": "573-221-4671",
            "fax_number": "573-221-4671"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18 RIDGEWOOD DR",
            "city": "HANNIBAL",
            "state": "MO",
            "postal_code": "634013056",
            "telephone_number": "573-221-4671",
            "fax_number": "573-221-4671"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSON GROUP HOME LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-09-16",
        "last_updated": "2017-04-09",
        "status": "A",
        "authorized_official_last_name": "CULP",
        "authorized_official_first_name": "LORA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OWNER/OPERATOR",
        "authorized_official_telephone_number": "573-221-4671",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "BSN, RN"
    },
    "taxonomies": [
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "MO",
            "license": "2500-12463",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jackson Group Home",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Hannibal, MO
• Providers in Hannibal, MO by specialty
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.