Provider Demographics
NPI:1578720397
Name:JACKSON FEILD HOMES
Entity Type:Organization
Organization Name:JACKSON FEILD HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-634-3217
Mailing Address - Street 1:546 WALNUT GROVE DR
Mailing Address - Street 2:
Mailing Address - City:JARRATT
Mailing Address - State:VA
Mailing Address - Zip Code:23867-8611
Mailing Address - Country:US
Mailing Address - Phone:434-634-3217
Mailing Address - Fax:434-348-3417
Practice Address - Street 1:546 WALNUT GROVE DR
Practice Address - Street 2:
Practice Address - City:JARRATT
Practice Address - State:VA
Practice Address - Zip Code:23867-8611
Practice Address - Country:US
Practice Address - Phone:434-634-3217
Practice Address - Fax:434-348-3417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA278-05322D00000X
VA1376323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1578720397Medicaid