Provider Demographics
NPI:1205020476
Name:JACKSONVILLE FAMILY MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:JACKSONVILLE FAMILY MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERLETA
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-938-3200
Mailing Address - Street 1:2587 HENDERSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5253
Mailing Address - Country:US
Mailing Address - Phone:910-938-3200
Mailing Address - Fax:910-938-3043
Practice Address - Street 1:2587 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5253
Practice Address - Country:US
Practice Address - Phone:910-938-3200
Practice Address - Fax:910-938-3043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36058261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD75607OtherUPIN
NC89011JHMedicaid