Provider Demographics
NPI:1023148434
Name:JACKSONVILLE CARE LLC
Entity type:Organization
Organization Name:JACKSONVILLE CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:W
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-643-0555
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:27310-0878
Mailing Address - Country:US
Mailing Address - Phone:336-643-0555
Mailing Address - Fax:336-643-0553
Practice Address - Street 1:182 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7238
Practice Address - Country:US
Practice Address - Phone:910-353-7111
Practice Address - Fax:910-353-2799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-067-013310400000X, 311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804343Medicaid