Basic Information
| Provider Information | |||||||||
| NPI: | 1720307895 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON COUNTY PSYCHOLOGICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 728 | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287790728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285862311 | ||||||||
| FaxNumber: | 8285865450 | ||||||||
| Practice Location | |||||||||
| Address1: | 3770 SKYLAND DR | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287798360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285862311 | ||||||||
| FaxNumber: | 8285865450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | DOUTHIT | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8285862311 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON COUNTY PSYCHOLOGICAL SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8302150 | 05 | NC | MEDICAID |