1215519418 NPI number — JACKSON HOSPITAL AND CLINIC, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215519418 NPI number — JACKSON HOSPITAL AND CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON HOSPITAL AND CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215519418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1722 PINE ST STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36106-1158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-293-8736
Provider Business Mailing Address Fax Number:
334-293-8738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2175 US HIGHWAY 31 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEATSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36022-2714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-568-2120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
HERRING
Authorized Official First Name:
TARA
Authorized Official Middle Name:
Authorized Official Title or Position:
REVENUE CYCLE DIRECTOR
Authorized Official Telephone Number:
334-240-2337

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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