Provider Demographics
NPI:1518299791
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:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETHENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CSAC
Authorized Official - Phone:919-682-4771
Mailing Address - Street 1:PO BOX 802
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27702-0802
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?:Yes
Parent Organization LBN:NEW OUTLOOK..SECOND CHANCE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-12
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103T00000X, 104100000X
NCMHL-032-506101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302362BMedicaid
NC8302362QMedicaid
NC8302703BMedicaid
NC8302703GMedicaid
NC8302362GMedicaid
NC8700391Medicaid