Provider Demographics
NPI:1588808240
Name:JACKSON FAMILY CARE HOME II
Entity Type:Organization
Organization Name:JACKSON FAMILY CARE HOME II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MCCULLERS
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-266-5291
Mailing Address - Street 1:5641 QUAIL COVEY LN
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-7901
Mailing Address - Country:US
Mailing Address - Phone:919-266-5291
Mailing Address - Fax:919-266-7901
Practice Address - Street 1:7112 OUTRIGGER DR
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:NC
Practice Address - Zip Code:27591-7240
Practice Address - Country:US
Practice Address - Phone:919-366-1513
Practice Address - Fax:919-366-1513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-26
Last Update Date:2009-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL092148261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health