Provider Demographics
NPI:1831060821
Name:HOME AWAY FROM HOME OF PUTNAM CO., INC.
Entity type:Organization
Organization Name:HOME AWAY FROM HOME OF PUTNAM CO., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-329-3208
Mailing Address - Street 1:3108 SAINT JOHNS AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4132
Mailing Address - Country:US
Mailing Address - Phone:386-385-3166
Mailing Address - Fax:386-385-3248
Practice Address - Street 1:680 OLD SAN MATEO RD
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:FL
Practice Address - Zip Code:32187-2220
Practice Address - Country:US
Practice Address - Phone:386-329-3208
Practice Address - Fax:386-385-3248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty