Healthcare Provider Details

I. General information

NPI: 1407154800
Provider Name (Legal Business Name): JELLICO COMMUNITY HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 SOUTH HIGHWAY 25W
WILLAIMSBURG KY
40769
US

IV. Provider business mailing address

188 HOSPITAL LANE
JELLICO TN
37762-4433
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-1183
  • Fax: 606-549-8107
Mailing address:
  • Phone: 423-784-7252
  • Fax: 423-784-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA071
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3007739
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3004431
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3002560
License Number StateKY

VIII. Authorized Official

Name: EVELYN GHULAM
Title or Position: CONTROLLER
Credential:
Phone: 423-784-1334