Provider Demographics
NPI:1770771750
Name:JACKSONVILLE BEHAVIOR AND MENTAL HEALTH
Entity type:Organization
Organization Name:JACKSONVILLE BEHAVIOR AND MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MADHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-353-0581
Mailing Address - Street 1:118 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6328
Mailing Address - Country:US
Mailing Address - Phone:910-353-0581
Mailing Address - Fax:910-939-4269
Practice Address - Street 1:156 MEMORIAL CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6322
Practice Address - Country:US
Practice Address - Phone:910-353-0680
Practice Address - Fax:910-353-3629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0855X
NC3758261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901904Medicaid
NC8901904Medicaid