Provider Demographics
NPI:1912021486
Name:MARY L MCCULLERS-JACKSON
Entity Type:Organization
Organization Name:MARY L MCCULLERS-JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LILLY
Authorized Official - Last Name:MCCULLERS JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-266-5291
Mailing Address - Street 1:5641 QUAIL COVEY LANE
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 1:501 BUNN ST
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-9177
Practice Address - Country:US
Practice Address - Phone:919-269-3060
Practice Address - Fax:919-266-7901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-06-26
Deactivation Date:2008-06-03
Deactivation Code:
Reactivation Date:2008-06-19
Provider Licenses
StateLicense IDTaxonomies
NCMHL092516311ZA0620X
NCMHL 092 516320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home