Provider Demographics
NPI:1508044975
Name:JACY1 DBA ANCHORAGE
Entity Type:Organization
Organization Name:JACY1 DBA ANCHORAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:218-287-1500
Mailing Address - Street 1:810 4TH ST S
Mailing Address - Street 2:SUITE 152
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560
Mailing Address - Country:US
Mailing Address - Phone:218-287-1500
Mailing Address - Fax:218-287-1267
Practice Address - Street 1:810 4TH ST S
Practice Address - Street 2:SUITE 152
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560
Practice Address - Country:US
Practice Address - Phone:218-287-1500
Practice Address - Fax:218-287-1267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1044799324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility