Active NPI
Julliet Jackson
- Adult Care Home Facility
- Port Charlotte, FL
National Provider Identifier
1922438464
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Adult Care Home Facility
- License
- 6905617
- Practice address
- 17345 Edgewater Dr
Port Charlotte, FL 33948-2343 - Phone
- (941) 766-0175
- NPI assigned
- Nov 20, 2013
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Adult Care Home Facility | 311ZA0620X | 6905617 | FL | Primary |
Addresses
Primary practice location
17345 Edgewater Dr
Port Charlotte, FL 33948-2343
Mailing address
17345 Edgewater Dr
Port Charlotte, FL 33948-2343
Phone (941) 766-0175
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 142038100 | Medicaid | FL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6905617 | FL | MD | Adult Care Home Facility |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1384905600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1384905600000",
"number": "1922438464",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "17345 EDGEWATER DR",
"city": "PORT CHARLOTTE",
"state": "FL",
"postal_code": "339482343",
"telephone_number": "941-766-0175"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "17345 EDGEWATER DR",
"city": "PORT CHARLOTTE",
"state": "FL",
"postal_code": "339482343",
"telephone_number": "941-766-0175"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "JULLIET",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2013-11-20",
"last_updated": "2013-11-20",
"status": "A"
},
"taxonomies": [
{
"code": "311ZA0620X",
"taxonomy_group": "",
"desc": "Custodial Care Facility, Adult Care Home",
"state": "FL",
"license": "6905617",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "142038100",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Port Charlotte, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.