Healthcare Provider Details

I. General information

NPI: 1790777696
Provider Name (Legal Business Name): JACK COUNTY HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 CHISHOLM TRL
JACKSBORO TX
76458
US

IV. Provider business mailing address

215 CHISHOLM TRL
JACKSBORO TX
76458-1403
US

V. Phone/Fax

Practice location:
  • Phone: 940-567-6633
  • Fax: 940-567-2895
Mailing address:
  • Phone: 940-567-6633
  • Fax: 940-567-2895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number000046
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number100322
License Number StateTX

VIII. Authorized Official

Name: MRS. KIM LEE
Title or Position: COO
Credential:
Phone: 940-567-6633