Provider Demographics
NPI:1629166327
Name:JACKSON FAMILY HOMES, INC.
Entity Type:Organization
Organization Name:JACKSON FAMILY HOMES, INC.
Other - Org Name:JACKSON SUPPORT SERVICES, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/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:704-846-2295
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:704-846-2295
Mailing Address - Fax:704-332-3510
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:704-846-2295
Practice Address - Fax:704-332-3510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8301472251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603382Medicaid
NC6603584Medicaid
NC8301472Medicaid