Provider Demographics
NPI:1326183948
Name:JACK MABLEY DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:JACK MABLEY DEVELOPMENTAL CENTER
Other - Org Name:EDISON HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-288-8330
Mailing Address - Street 1:1120 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1258
Mailing Address - Country:US
Mailing Address - Phone:815-288-8331
Mailing Address - Fax:815-288-7275
Practice Address - Street 1:1120 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1258
Practice Address - Country:US
Practice Address - Phone:815-288-8331
Practice Address - Fax:815-288-7275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1376525204OtherCENTER NPI NUMBER