Basic Information
| Provider Information | |||||||||
| NPI: | 1770966491 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON RECOVERY CENTERS, INC. | ||||||||
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| OtherOrganizationName: | CHILD AND ADOLESCENT RECOVERY HOSPITAL CRISIS AND STABILIZATION UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122342300 | ||||||||
| FaxNumber: | 7122342398 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 WEST 4TH STREET | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122661800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | KERMIT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7122342300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
No ID Information.