=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073264107
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON HOSPITAL AND CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2022
-----------------------------------------------------
Last Update Date | 02/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 PINE ST
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36106-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-293-8147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1725 PINE ST
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36106-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-293-8147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR-REVENUE CYCLE INTEGRATION
-----------------------------------------------------
Name | MELODY COWDREY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 334-293-8147
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------