Provider Demographics
NPI:1790016517
Name:WOLFE & JACKSON GROUP HOME, INC
Entity Type:Organization
Organization Name:WOLFE & JACKSON GROUP HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZELMA
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-788-3004
Mailing Address - Street 1:PO BOX 12002
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27117-2002
Mailing Address - Country:US
Mailing Address - Phone:336-722-8354
Mailing Address - Fax:336-722-8354
Practice Address - Street 1:744 E SPRAGUE ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-3246
Practice Address - Country:US
Practice Address - Phone:336-788-3004
Practice Address - Fax:336-529-6454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-18
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 253Z00000X
NCMHL-034-276320900000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care