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Organization
MACON MENTOR ACADEMY
Active
Organization
MACON MENTOR ACADEMY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JERRY LEE MACON JR. K-12 EDUCATOR (BSW) (EXECUTIVE DIRECTOR)
(317) 480-2949
Entity
Organization
Contact information
Practice address
3451 N KINGSLEY DR, BLOOMINGTON, IN 47404-1717
(317) 480-2949
(812) 369-4082
Mailing address
3451 N KINGSLEY DR, BLOOMINGTON, IN 47404-1717
(317) 480-2949
(812) 369-4082
Taxonomy
Speciality
Code
Description
License number
State
385HR2060X
Child Intellectual and/or Developmental Disabilities Respite Care
Primary
—
IN
Other
Enumeration date
10/01/2012
Last updated
10/01/2012
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