Macon Mentor Academy

Primary specialty

Child Intellectual and/or Developmental Disabilities Respite CareTaxonomy code 385HR2060X

Legal business name

MACON MENTOR ACADEMY

Practice address

3451 N Kingsley Dr
Bloomington, IN 47404-1717

Phone

(317) 480-2949

Fax

(812) 369-4082

NPI assigned

Oct 1, 2012

Organization subpart

No

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

Authorized official

Name

Mr. Jerry Lee Macon Jr., K-12 EDUCATOR (BSW)

Title

Executive Director

Phone

(317) 480-2949

Specialties & licenses 1

Addresses

Other identifiers 1

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

{
    "created_epoch": "1349049600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1349049600000",
    "number": "1609127646",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3451 N KINGSLEY DR",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474041717",
            "telephone_number": "317-480-2949",
            "fax_number": "812-369-4082"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3451 N KINGSLEY DR",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474041717",
            "telephone_number": "317-480-2949",
            "fax_number": "812-369-4082"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MACON MENTOR ACADEMY",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-01",
        "last_updated": "2012-10-01",
        "status": "A",
        "authorized_official_last_name": "MACON",
        "authorized_official_first_name": "JERRY",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "317-480-2949",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "K-12 EDUCATOR (BSW)"
    },
    "taxonomies": [
        {
            "code": "385HR2060X",
            "taxonomy_group": "",
            "desc": "Respite Care, Respite Care, Intellectual and/or Developmental Disabilities, Child",
            "state": "IN",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201091380 A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Allan Alexander Mackay, MD
• Joseph Michael Mackey, M.D.
• Talula Mackey
• Nancy S. Macklin, N.P.
• Pamela Ann Maclaughlin, DNP, PMHNP-BC
• Amber Macroberts
• Justin Macy, PHARMD
• Regina Macy, NP
• Benjamin Maddock
• Amanda Elizabeth Madsen, ATC

• Child Intellectual and/or Developmental Disabilities Respite Care in Bloomington, IN
• Providers in Bloomington, IN by specialty
• Child Intellectual and/or Developmental Disabilities Respite Care in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2012; 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.