Healthcare Provider Details

I. General information

NPI: 1770756447
Provider Name (Legal Business Name): JEFFERSON COMPREHENSIVE HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 HIGHWAY 33
FAYETTE MS
39069-4546
US

IV. Provider business mailing address

PO BOX 98
FAYETTE MS
39069-0098
US

V. Phone/Fax

Practice location:
  • Phone: 601-786-3475
  • Fax: 601-786-9980
Mailing address:
  • Phone: 601-786-3475
  • Fax: 601-786-9980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: SHIRLEY A. ELLIS
Title or Position: CEO
Credential:
Phone: 601-786-3475