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Organization
JACKSON HOME, INC.
Active
Organization
JACKSON HOME, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. GLENDA T JACKSON (DIRECTOR)
(910) 628-7171
Entity
Organization
Contact information
Practice address
509 HOLLY ST, FAIRMONT, NC 28340-1705
(910) 628-7171
Mailing address
509 HOLLY ST, FAIRMONT, NC 28340-1705
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
MHL078158
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6603889
—
NC
Enumeration date
06/14/2007
Last updated
08/22/2020
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