Basic Information
| Provider Information | |||||||||
| NPI: | 1558542555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORRISON | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 BENTON ST | ||||||||
| Address2: | # 8 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307203432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068769015 | ||||||||
| FaxNumber: | 7068769015 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 SHUGART RD | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705100 | ||||||||
| FaxNumber: | 7062705102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2007 | ||||||||
| LastUpdateDate: | 11/18/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | RN#169445 | GA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.