Healthcare Provider Details

I. General information

NPI: 1295037372
Provider Name (Legal Business Name): JEFFERSON COMPREHENSIVE HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 02/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 N. DR. MLK JR. STREET
NATCHEZ MS
39120-3157
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 StateMS

VIII. Authorized Official

Name: MRS. SHIRLEY A ELLIS-STAMPLEY
Title or Position: CHEIF EXECUTIVE OFFICER
Credential: MBA
Phone: 601-786-3475