Healthcare Provider Details

I. General information

NPI: 1063712701
Provider Name (Legal Business Name): JACKSON PHYSICIAN CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 JETT DR
JACKSON KY
41339-9622
US

IV. Provider business mailing address

540 JETT DR
JACKSON KY
41339-9622
US

V. Phone/Fax

Practice location:
  • Phone: 606-666-6300
  • Fax: 606-666-6118
Mailing address:
  • Phone: 606-666-6300
  • Fax: 606-666-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateTN

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR
Credential:
Phone: 877-892-9813