Provider Demographics
NPI:1154465243
Name:BUSHNELL DIX HILL JONES 694110
Entity Type:Organization
Organization Name:BUSHNELL DIX HILL JONES 694110
Other - Org Name:JACKSONVILLE DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE ASST
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-479-2120
Mailing Address - Street 1:1201 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3339
Mailing Address - Country:US
Mailing Address - Phone:217-479-2120
Mailing Address - Fax:217-243-8920
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3339
Practice Address - Country:US
Practice Address - Phone:217-479-2120
Practice Address - Fax:217-243-8920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL694110Medicaid