Healthcare Provider Details

I. General information

NPI: 1154887040
Provider Name (Legal Business Name): JESC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2019
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 WEST SECOND STREET SUITE A
JASPER IN
47546
US

IV. Provider business mailing address

3800 VENETIAN WAY
NEWBURGH IN
47630-8257
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-6103
  • Fax:
Mailing address:
  • Phone: 812-477-6103
  • Fax: 812-469-3285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMMY SIMS
Title or Position: BILLING MANAGER
Credential:
Phone: 812-266-2903