Healthcare Provider Details

I. General information

NPI: 1114134814
Provider Name (Legal Business Name): JACKSON WOMENS CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 JETT DR
JACKSON KY
41339-9622
US

IV. Provider business mailing address

PO BOX 790
JACKSON KY
41339-0790
US

V. Phone/Fax

Practice location:
  • Phone: 606-666-6240
  • Fax:
Mailing address:
  • Phone: 606-666-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number21623
License Number StateKY

VIII. Authorized Official

Name: LORETTA L CAMPBELL
Title or Position: CLINIC COORDINATOR
Credential:
Phone: 606-693-0531