=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518395342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON COUNTY HOSPITAL DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2013
-----------------------------------------------------
Last Update Date | 08/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4250 HOSPITAL DR
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-718-2822
-----------------------------------------------------
Fax | 850-718-2803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4250 HOSPITAL DR
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-718-2822
-----------------------------------------------------
Fax | 850-718-2803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MRS. BROOKE DONALDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-718-2822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NR1301X
-----------------------------------------------------
Taxonomy Name | Rural Acute Care Hospital
-----------------------------------------------------
License Number | 3999
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------