Healthcare Provider Details

I. General information

NPI: 1710265905
Provider Name (Legal Business Name): JACKSON HOSPITAL AND CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 PINE ST SUITE 203
MONTGOMERY AL
36106-0165
US

IV. Provider business mailing address

1722 PINE ST SUITE 503
MONTGOMERY AL
36106-1103
US

V. Phone/Fax

Practice location:
  • Phone: 334-293-8877
  • Fax: 334-293-6803
Mailing address:
  • Phone: 334-270-9914
  • Fax: 334-270-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD.30788
License Number StateAL

VIII. Authorized Official

Name: MR. PETER VERRECCHIA
Title or Position: CFO
Credential:
Phone: 334-293-8000