Healthcare Provider Details

I. General information

NPI: 1184611741
Provider Name (Legal Business Name): JEFFERSON COUNTY NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 MAIN ST
FAYETTE MS
39069-5524
US

IV. Provider business mailing address

PO BOX 1089
FAYETTE MS
39069-1089
US

V. Phone/Fax

Practice location:
  • Phone: 601-786-3888
  • Fax: 601-786-9400
Mailing address:
  • Phone: 601-786-3888
  • Fax: 601-786-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number711
License Number StateMS

VIII. Authorized Official

Name: MRS. MONTINA FLETCHER BOLTON
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-786-3888