Healthcare Provider Details

I. General information

NPI: 1952949968
Provider Name (Legal Business Name): JACKSON HOSPITAL AND CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2019
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4154 CARMICHAEL RD
MONTGOMERY AL
36106-2866
US

IV. Provider business mailing address

1722 PINE ST STE 203
MONTGOMERY AL
36106-1158
US

V. Phone/Fax

Practice location:
  • Phone: 334-271-5959
  • Fax: 334-272-8775
Mailing address:
  • Phone: 334-293-8736
  • Fax: 334-293-8738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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