Provider Demographics
NPI:1124212873
Name:JACY 2, LLC
Entity Type:Organization
Organization Name:JACY 2, LLC
Other - Org Name:WINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-9530
Mailing Address - Street 1:1096 E 260TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071-8880
Mailing Address - Country:US
Mailing Address - Phone:320-255-9530
Mailing Address - Fax:
Practice Address - Street 1:319 CSAH #20
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355
Practice Address - Country:US
Practice Address - Phone:320-255-9530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10473433245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children