Provider Demographics
NPI:1013124957
Name:HILL, JIMMIE WILSON (CEO)
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:WILSON
Last Name:HILL
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 HALLS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-5722
Mailing Address - Country:US
Mailing Address - Phone:252-745-5761
Mailing Address - Fax:252-745-7750
Practice Address - Street 1:554 HALLS CREEK RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-5722
Practice Address - Country:US
Practice Address - Phone:252-745-5761
Practice Address - Fax:252-745-7750
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-069-006251C00000X, 251S00000X, 385H00000X
NCMH069-006320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered251S00000XAgenciesCommunity/Behavioral Health
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409210Medicaid