Provider Demographics
NPI:1548523186
Name:HOSPICE OF JACKSON - HOSPICE HOME
Entity type:Organization
Organization Name:HOSPICE OF JACKSON - HOSPICE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP - CMO, CEO - HFAMG
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-205-6407
Mailing Address - Street 1:2150 KINGSBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1300
Mailing Address - Country:US
Mailing Address - Phone:517-817-7600
Mailing Address - Fax:517-817-7615
Practice Address - Street 1:2150 KINGSBROOKE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1300
Practice Address - Country:US
Practice Address - Phone:517-817-7600
Practice Address - Fax:517-817-7615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPICE OF JACKSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-19
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1050000017251G00000X
MI1070000432315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
No251G00000XAgenciesHospice Care, Community Based