Healthcare Provider Details

I. General information

NPI: 1376964379
Provider Name (Legal Business Name): HEALTHSTAT ON-SITE CLINIC/UNIFIED BRANDS JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 ARMORY RD
VICKSBURG MS
39183-7431
US

IV. Provider business mailing address

4651 CHARLOTTE PARK DR SUITE 300
CHARLOTTE NC
28217-1956
US

V. Phone/Fax

Practice location:
  • Phone: 989-644-3331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL JOHNSON PATTON
Title or Position: DIRECTOR OF RISK MANAGEMENT
Credential:
Phone: 704-936-5546