Healthcare Provider Details

I. General information

NPI: 1992377873
Provider Name (Legal Business Name): JACKSON HOSPITAL AND CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 PINE ST STE 204
MONTGOMERY AL
36106-1154
US

IV. Provider business mailing address

1722 PINE ST STE 203
MONTGOMERY AL
36106-1158
US

V. Phone/Fax

Practice location:
  • Phone: 334-293-8877
  • Fax: 334-293-6803
Mailing address:
  • Phone: 334-293-8736
  • Fax: 334-293-8738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: TARA HERRING
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 334-293-8736