Healthcare Provider Details

I. General information

NPI: 1033809959
Provider Name (Legal Business Name): MOBILIZING AFRICAN AMERICAN MOTHERS THROUGH EMPOWERMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 05/12/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 FAYETTEVILLE ST
DURHAM NC
27707-2391
US

IV. Provider business mailing address

1208 FAYETTEVILLE ST
DURHAM NC
27707-2391
US

V. Phone/Fax

Practice location:
  • Phone: 919-709-3120
  • Fax: 919-709-3120
Mailing address:
  • Phone: 919-709-3120
  • Fax: 919-709-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM1000X
TaxonomyMigrant Health Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. MAYA JACKSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 919-709-3120