Provider Demographics
NPI:1255497244
Name:NEW OUTLOOK SECOND CHANCE, INC.
Entity Type:Organization
Organization Name:NEW OUTLOOK SECOND CHANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BETHENA
Authorized Official - Middle Name:MECHELE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LCAS-A
Authorized Official - Phone:919-682-4771
Mailing Address - Street 1:2604 CARVER ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2796
Mailing Address - Country:US
Mailing Address - Phone:919-682-4771
Mailing Address - Fax:919-683-2641
Practice Address - Street 1:2604 CARVER ST
Practice Address - Street 2:SUITE C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2796
Practice Address - Country:US
Practice Address - Phone:919-682-4771
Practice Address - Fax:919-683-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC632008251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8700391Medicaid