Jackson Home, Inc.

Primary specialty

Emotionally Disturbed Childrens' Residential Treatment FacilityTaxonomy code 322D00000X

License

MHL078158 Issued in NC

Legal business name

JACKSON HOME, INC.

Practice address

509 Holly St
Fairmont, NC 28340-1705

Phone

(910) 628-7171

NPI assigned

Jun 14, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Glenda T Jackson

Title

Director

Phone

(910) 628-7171

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1181779200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1285838805",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "509 HOLLY ST",
            "city": "FAIRMONT",
            "state": "NC",
            "postal_code": "283401705"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "509 HOLLY ST",
            "city": "FAIRMONT",
            "state": "NC",
            "postal_code": "283401705",
            "telephone_number": "910-628-7171"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSON HOME, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-14",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "GLENDA",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "910-628-7171",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "322D00000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Emotionally Disturbed Children",
            "state": "NC",
            "license": "MHL078158",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603889",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Emotionally Disturbed Childrens' Residential Treatment Facility in Fairmont, NC
• Providers in Fairmont, NC by specialty
• Emotionally Disturbed Childrens' Residential Treatment Facility in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.