Provider Demographics
NPI:1629182142
Name:JEFFERSON SENIOR CITIZEN'S CENTER, INC.
Entity type:Organization
Organization Name:JEFFERSON SENIOR CITIZEN'S CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-342-0242
Mailing Address - Street 1:1155 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-2246
Mailing Address - Country:US
Mailing Address - Phone:850-342-0242
Mailing Address - Fax:850-342-0630
Practice Address - Street 1:1155 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-2246
Practice Address - Country:US
Practice Address - Phone:850-342-0242
Practice Address - Fax:850-342-0630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5986251B00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024875402Medicaid