Healthcare Provider Details

I. General information

NPI: 1124212873
Provider Name (Legal Business Name): JACY 2, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 CSAH #20
LITCHFIELD MN
55355
US

IV. Provider business mailing address

1096 E 260TH ST
NEW PRAGUE MN
56071-8880
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-9530
  • Fax:
Mailing address:
  • Phone: 320-255-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number1047343
License Number StateMN

VIII. Authorized Official

Name: CARMEN MARIE WILSON
Title or Position: OWNER
Credential:
Phone: 320-255-9530