Provider Demographics
NPI:1275549859
Name:JACKSON RIVER ENTERPRISES, INC.
Entity Type:Organization
Organization Name:JACKSON RIVER ENTERPRISES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WALTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-962-3441
Mailing Address - Street 1:825 W EDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24426-2759
Mailing Address - Country:US
Mailing Address - Phone:540-962-3441
Mailing Address - Fax:540-965-8530
Practice Address - Street 1:825 W EDGEMONT DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:VA
Practice Address - Zip Code:24426-2759
Practice Address - Country:US
Practice Address - Phone:540-962-3441
Practice Address - Fax:540-965-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170300000X
VA010173515251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No170300000XOther Service ProvidersGenetic Counselor, MSGroup - Multi-Specialty