Healthcare Provider Details

I. General information

NPI: 1457432460
Provider Name (Legal Business Name): JACKSON COUNTY HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 S WELLS ST
EDNA TX
77957-4098
US

IV. Provider business mailing address

1013 S WELLS ST
EDNA TX
77957-4098
US

V. Phone/Fax

Practice location:
  • Phone: 361-782-7800
  • Fax: 361-782-7495
Mailing address:
  • Phone: 361-782-7800
  • Fax: 361-782-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ASA B WILSON
Title or Position: ADMINSITRATOR/CEO
Credential:
Phone: 361-782-7810