Provider Demographics
NPI:1568652501
Name:JACKSON FAMILY HOMES, INC.
Entity Type:Organization
Organization Name:JACKSON FAMILY HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-905-5577
Mailing Address - Street 1:11808 PROVINCETOWNE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-9165
Mailing Address - Country:US
Mailing Address - Phone:704-905-5577
Mailing Address - Fax:704-846-2295
Practice Address - Street 1:11808 PROVINCETOWNE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-9165
Practice Address - Country:US
Practice Address - Phone:704-905-5577
Practice Address - Fax:704-846-2295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON FAMILY HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6603584251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301582Medicaid