Provider Demographics
NPI:1023272663
Name:WOLFE & JACKSON FAMILY CARE HOME
Entity type:Organization
Organization Name:WOLFE & JACKSON FAMILY CARE HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZELMA
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-722-8354
Mailing Address - Street 1:PO BOX 12002
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27117-2002
Mailing Address - Country:US
Mailing Address - Phone:336-722-8354
Mailing Address - Fax:
Practice Address - Street 1:3913 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-3410
Practice Address - Country:US
Practice Address - Phone:336-661-9032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOLFE & JACKSON FAMILY CARE HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802068Medicaid