Healthcare Provider Details

I. General information

NPI: 1588723241
Provider Name (Legal Business Name): JAMESTOWN HEALTHCARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 N MAIN ST
JAMESTOWN KY
42629
US

IV. Provider business mailing address

PO BOX 966
JAMESTOWN KY
42629
US

V. Phone/Fax

Practice location:
  • Phone: 270-343-2597
  • Fax: 270-343-2598
Mailing address:
  • Phone: 270-343-2597
  • Fax: 270-343-2598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33028
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38782
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37317
License Number StateKY

VIII. Authorized Official

Name: JERRY WAYNE LAWSON
Title or Position: PRESIDENT
Credential: MD
Phone: 270-343-2597