Provider Demographics
NPI:1568495588
Name:MARSHALL-JACKSON MENTAL HEALTH BD., INC.
Entity type:Organization
Organization Name:MARSHALL-JACKSON MENTAL HEALTH BD., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERMIN EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:GARGIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:256-582-4240
Mailing Address - Street 1:2409 HOMER CLAYTON DR
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-2207
Mailing Address - Country:US
Mailing Address - Phone:256-582-3203
Mailing Address - Fax:256-582-3216
Practice Address - Street 1:2409 HOMER CLAYTON DR
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-2207
Practice Address - Country:US
Practice Address - Phone:256-582-3203
Practice Address - Fax:256-582-3216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510081221OtherBCBS ALLKIDS
AL528400680OtherMCR/MCD CROSSOVER GROUP #
AL590000013Medicaid
AL1568495588OtherUBH PROVIDER
AL330000013Medicaid
AL330034013Medicaid
AL590000013Medicaid
AL510081221OtherBCBS ALLKIDS
AL590000013Medicaid