Healthcare Provider Details

I. General information

NPI: 1477029072
Provider Name (Legal Business Name): JACKSON HOSPITAL AND CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 PINE ST STE 603
MONTGOMERY AL
36106-1114
US

IV. Provider business mailing address

1722 PINE ST STE 503
MONTGOMERY AL
36106-1160
US

V. Phone/Fax

Practice location:
  • Phone: 334-264-2422
  • Fax: 334-264-9294
Mailing address:
  • Phone: 334-293-8736
  • Fax: 334-293-8736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TARA HERRING
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 334-240-2337