Healthcare Provider Details

I. General information

NPI: 1336229871
Provider Name (Legal Business Name): JAQUITH NURSING HOME - MADISON INN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 HWY 468 WEST
WHITFIELD MS
39193-0157
US

IV. Provider business mailing address

P.O. BOX 1 FISCAL SERVICES 3550 HWY 468 WEST
WHITFIELD MS
39193-0157
US

V. Phone/Fax

Practice location:
  • Phone: 601-351-8000
  • Fax: 601-351-8586
Mailing address:
  • Phone: 601-351-8000
  • Fax: 601-351-8586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number945
License Number StateMS

VIII. Authorized Official

Name: MR. JAMES G CHASTAIN
Title or Position: DIRECTOR
Credential:
Phone: 601-351-8000