Provider Demographics
NPI:1457476913
Name:WOLFE & JACKSON FAMILY CARE HOME
Entity Type:Organization
Organization Name:WOLFE & JACKSON FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZELMA
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:335-722-8354
Mailing Address - Street 1:PO BOX 12002
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27117-2002
Mailing Address - Country:US
Mailing Address - Phone:336-722-8354
Mailing Address - Fax:336-722-8354
Practice Address - Street 1:744 EAST SPRAGUE STREET
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-3246
Practice Address - Country:US
Practice Address - Phone:336-722-8354
Practice Address - Fax:336-722-8354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL034020311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802068OtherPROVIDER #
NC237701279PMedicaid
NC237701279PMedicaid