Provider Demographics
NPI:1124372586
Name:JESSIE CRAWFORD RECOVERY CENTER, INC.
Entity Type:Organization
Organization Name:JESSIE CRAWFORD RECOVERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-241-4285
Mailing Address - Street 1:1213 N SHERMAN AVE
Mailing Address - Street 2:#323
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4236
Mailing Address - Country:US
Mailing Address - Phone:608-467-9134
Mailing Address - Fax:608-467-9135
Practice Address - Street 1:2101 N SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3932
Practice Address - Country:US
Practice Address - Phone:608-241-4285
Practice Address - Fax:608-241-4286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2986261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124372586Medicaid