Healthcare Provider Details

I. General information

NPI: 1699794578
Provider Name (Legal Business Name): JELLICO COMMUNITY HOSPITAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 HOSPITAL LANE
JELLICO TN
37762-4400
US

IV. Provider business mailing address

PO BOX 844869
DALLAS TX
75284-4869
US

V. Phone/Fax

Practice location:
  • Phone: 423-784-1334
  • Fax: 423-784-1136
Mailing address:
  • Phone: 423-784-1334
  • Fax: 423-784-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number0000000007
License Number StateTN

VIII. Authorized Official

Name: EVELYN GHULAM
Title or Position: CONTROLLER
Credential:
Phone: 423-784-1334