1649317686 NPI number — JACKSON COUNTY HEALTH DEPARTMENT

Table of content: (NPI 1649317686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649317686 NPI number — JACKSON COUNTY HEALTH DEPARTMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON COUNTY HEALTH DEPARTMENT
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:
6
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:
1649317686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
341 STAN EVANS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30549-2909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-367-5204
Provider Business Mailing Address Fax Number:
706-367-9023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
341 STAN EVANS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30549-2909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-367-5204
Provider Business Practice Location Address Fax Number:
706-367-9023
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOGGANS
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
S
Authorized Official Title or Position:
HEALTH DIRECTOR
Authorized Official Telephone Number:
706-583-2870

Provider Taxonomy Codes

  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000456574F . This is a "PEACH STATE HEALTH PLAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 340403 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 804035 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10073783 . This is a "AMERIGROUP CORP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000456574F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52050223 . This is a "BCBS GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 8108822 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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