MEDICARE: JEFFERSON COUNTY PUBLIC HEALTH SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency	2201600	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2201600	OTHER	NY	CHHA PROVIDER NUMBER

General Provider Information

NPI Number	:	1598822587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFERSON COUNTY PUBLIC HEALTH SERVICE

Provider Business Mailing Address
First Line	:	531 MEADE ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-1225
Country	:	US
Telephone Number	:	315-786-3710
Fax Number	:	315-786-3761

Provider Business Practice Location Address
First Line	:	531 MEADE ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-1225
Country	:	US
Telephone Number	:	315-786-3710
Fax Number	:	315-786-3761

Authorized Official
Title or Position	:	ACCOUNTANT
Name	:	DORENA LOUISE KIMBALL
Credential	:
Telephone Number	:	135-786-3742

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	08/22/2020

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