Provider Demographics
NPI:1750821229
Name:JACKSONVILLE TREATMENT CENTER
Entity Type:Organization
Organization Name:JACKSONVILLE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPONSOR
Authorized Official - Prefix:
Authorized Official - First Name:MACY
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:HAMM
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:919-656-1633
Mailing Address - Street 1:1112 SILVER OAKS CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-9359
Mailing Address - Country:US
Mailing Address - Phone:919-656-1633
Mailing Address - Fax:
Practice Address - Street 1:291 HUFF DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7370
Practice Address - Country:US
Practice Address - Phone:910-347-2205
Practice Address - Fax:910-347-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-03
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-067-166261QM2800X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone