Provider Demographics
NPI:1265758916
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:EXECUTIVE DIRECTOR
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:336-749-7660
Mailing Address - Street 1:PO BOX 4912
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27115-4912
Mailing Address - Country:US
Mailing Address - Phone:336-245-0303
Mailing Address - Fax:336-722-8354
Practice Address - Street 1:3913 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-3410
Practice Address - Country:US
Practice Address - Phone:336-661-0923
Practice Address - Fax:336-793-1496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
NCMHL 034-254320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3419271Medicaid