Organization
JACKSON STYLE AGENCY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CLEOTHA JACKSON (ASSISTANT ADMINISTRATOR)
(816) 765-9990
Entity
Organization
Contact information
Practice address
213 BLUE RIDGE EXT, GRANDVIEW, MO 64030-1603
(816) 765-9990
(816) 765-9987
Mailing address
213 BLUE RIDGE EXT, GRANDVIEW, MO 64030-1603
(816) 765-9990
(816) 765-9987
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Enumeration date
01/03/2007
Last updated
07/10/2007
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