WOLFE & JACKSON GROUP HOME, INC. NPI 1265758916

Community Based Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities in Winston Salem, NC

Organization Community Based Residential Treatment Fa...

About WOLFE & JACKSON GROUP HOME, INC.

Wolfe & Jackson Group Home, Inc. is a provider established in Winston Salem, North Carolina specializing in community based residential treatment facility, mental retardation and/or developmental disabilities. The NPI number of Wolfe & Jackson Group Home, Inc. is 1265758916 and was assigned on April 2010. The practitioner's primary taxonomy code is 320900000X with license number MHL 034-254 (NC). The provider is registered as an organization and their NPI record was last updated 3 years ago. The authorized official of this NPI record is Mrs. Zelma Jackson- Wolfe (Executive Director)

NPI

1265758916

Provider NameWOLFE & JACKSON GROUP HOME, INC.
Provider Location Address3913 INDIANA AVE WINSTON SALEM, NC 27105
Provider Mailing AddressPO BOX 4912 WINSTON SALEM, NC 27115
NPI Entity TypeOrganization
Is Sole Proprietor?N/A
Is Organization Subpart?No
Enumeration Date04-20-2010
Last Update Date04-29-2017

Primary Taxonomy

Taxonomy Code320900000X
ClassificationCommunity Based Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities
TypeResidential Treatment Facilities
License No.MHL 034-254
License StateNC
Taxonomy DescriptionA home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities.

Business Address

WOLFE & JACKSON GROUP HOME, INC.
3913 INDIANA AVE
WINSTON SALEM, NC
ZIP 27105
Phone: (336) 661-0923
Fax: (336) 793-1496

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Mailing Address

WOLFE & JACKSON GROUP HOME, INC.
PO BOX 4912
WINSTON SALEM, NC
ZIP 27115
Phone: (336) 245-0303
Fax: (336) 722-8354

Authorized Official

Authorized Official NameMRS. ZELMA JACKSON- WOLFE
Authorized Official TitleEXECUTIVE DIRECTOR
Authorized Official Phone(336) 749-7660

Additional Identifiers


Additional identifier(s) currently or formerly used as an identifier for the provider. The codes may include UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers.

Identifier Type / Code Identifier State
3419271MEDICAID (05)NC

Other Providers at the same location


The following provider is registered at the same or nearby location.

NPI Name / Type Taxonomy Address
1023272663WOLFE & JACKSON FAMILY CARE HOME
Organization
Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities3913 INDIANA AVE
WINSTON SALEM, NC 27105
(336) 661-9032

NPI Footnotes

What is the National Provider Indentifier (NPI)?
The NPI is 10-position all-numeric identification number assigned by the NPPES to uniquely identify a health care provider.

Provider Location Address
The location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.

Provider Mailing Address
The mailing address of the provider being identified. This address may contain the same information as the provider location address.

Entity Type Code
The code describing the type of health care provider that is being assigned an NPI.
The entity type codes are:
1 = Person: individual human being who furnishes health care;
2 = Non-person: entity other than an individual human being that furnishes health care (Examples: hospital, SNF, hospital subunit, pharmacy, or HMO)

What is a Subpart?
Subparts are the components and separate physical locations of organization health care providers. Subpart examples include:
Hospital components include outpatient departments, surgical centers, psychiatric units, and laboratories. These components are often separately licensed or certified by States and may exist at physical locations other than that of the hospital of which they are a component.

Provider Other Organization Name
The other organization name is the alternative last name by which the provider is or has been known (if an individual) or other name by which the organization provider is or has been known. The code identifying the type of other name. The provider other organization name codes are:
1 = former name;
2 = professional name;
3 = doing business as (d/b/ a) name;
4 = former legal business name; :
5 = other.

Provider Enumeration Date
The date the provider was assigned a unique identifier (assigned an NPI).

Last Update Date
The date that a NPI record was last updated or changed.

Primary Taxonomy Code
The primary taxonomy code defines the provider type, classification, and specialization. There could be only one primary taxonomy code per NPI record. For individual NPIs the license data is associated to the taxonomy code.

Authorized Official Name
The name of the person authorized to submit the NPI application or to officially change data for a health care provider.