NPIMap

Organization Active NPI

Illinois Department of Human Services

  • Intellectual Disabilities Intermediate Care Facility
  • Dixon, IL
National Provider Identifier
1376525204
Registry record updated Dec 22, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
830600 Issued in IL
Legal business name
ILLINOIS DEPARTMENT OF HUMAN SERVICES
Practice address
1120 Washington Ave
Dixon, IL 61021-1258
Phone
(815) 288-8301
Fax
(815) 288-8398
NPI assigned
Nov 16, 2005
Last updated
Dec 22, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 22, 2016

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

Authorized official

Name
Debra Muhlstadt
Title
Fiscal Administrator, Sodc Operatio
Phone
(815) 288-8335

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 830600 IL Primary

Addresses

Primary practice location

1120 Washington Ave
Dixon, IL 61021-1258

Mailing address

1120 Washington Ave
Dixon, IL 61021-1258
Phone (815) 288-8301

Other names 1

  • Jack Mabley Developmental Center Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031113000414 IL Part B Supplier - Clinic/Group Practice 9830003920 Receives reassigned benefits from 43 practitioners
16 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Centralia, IL; Waukegan, IL; Park Forest, IL; Kankakee, IL; Hines, IL; Dwight, IL; Dixon, IL; Chicago, IL…

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1376525204. Details of each certification follow.

  • CCN 14G008 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 14G008

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
JACK MABLEY DEVELOPEMENTAL CTR
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Aug 2, 1982
Last certification
May 23, 2025
Beds
119
Ownership / control type
Private (non-profit)
Facility address
1120 Washington Avenue
Dixon, IL 61021

Other NPIs on the same Medicare enrollment 16

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 16

National Provider Directory

National Provider Directory
Tax ID family
Elisabeth Ludeman Center292 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Locations

100 S Grand Ave E
Springfield, IL 62762

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1132099200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1482364800000",
    "number": "1376525204",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1120 WASHINGTON AVE",
            "city": "DIXON",
            "state": "IL",
            "postal_code": "610211258",
            "telephone_number": "815-288-8301",
            "fax_number": "815-288-8398"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1120 WASHINGTON AVE",
            "city": "DIXON",
            "state": "IL",
            "postal_code": "610211258",
            "telephone_number": "815-288-8301",
            "fax_number": "815-288-8398"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ILLINOIS DEPARTMENT OF HUMAN SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-16",
        "last_updated": "2016-12-22",
        "status": "A",
        "authorized_official_last_name": "MUHLSTADT",
        "authorized_official_first_name": "DEBRA",
        "authorized_official_title_or_position": "FISCAL ADMINISTRATOR, SODC OPERATIO",
        "authorized_official_telephone_number": "815-288-8335"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "IL",
            "license": "830600",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jack Mabley Developmental Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Dixon, IL

Sources for this page

Verify at the official NPI Registry.