=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073696357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON COUNTY HOSPITAL DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 S. THIRD STREET
-----------------------------------------------------
City | GANADO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77962-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-771-3571
-----------------------------------------------------
Fax | 361-771-3574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1013 S WELLS ST
-----------------------------------------------------
City | EDNA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77957-4098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-782-5241
-----------------------------------------------------
Fax | 361-782-7495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/CEO
-----------------------------------------------------
Name | MARCELLA VANA HENKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 361-782-5241
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------