Healthcare Provider Details

I. General information

NPI: 1780894253
Provider Name (Legal Business Name): JEFFERSON COUNTY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 MAIN STREET
FAYETTE MS
39069
US

IV. Provider business mailing address

870 MAIN STREET
FAYETTE MS
39069
US

V. Phone/Fax

Practice location:
  • Phone: 601-786-3401
  • Fax: 601-786-3400
Mailing address:
  • Phone: 601-786-3401
  • Fax: 601-786-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14997
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number07965
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16670
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number14721
License Number StateMS

VIII. Authorized Official

Name: MR. JERRY KENNEDY
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-786-3401