Provider Demographics
NPI:1225729783
Name:LOCUST STREET RESOURCE CENTER - JACKSONVILLE
Entity Type:Organization
Organization Name:LOCUST STREET RESOURCE CENTER - JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-854-3166
Mailing Address - Street 1:320 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1648
Mailing Address - Country:US
Mailing Address - Phone:217-854-3166
Mailing Address - Fax:217-854-3778
Practice Address - Street 1:60 E CENTRAL PARK PLZ
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2071
Practice Address - Country:US
Practice Address - Phone:217-854-3166
Practice Address - Fax:217-854-3778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOCUST STREET RESOURCE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)