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General NPI Number Information
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NPI Number | 1679596860
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Entity Type | Organization
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Legal Business Name | ST DOMINIC-JACKSON MEMORIAL HOSPITAL
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 969 LAKELAND DR
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City | JACKSON
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State | MS
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Zip | 39216-4606
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Country | US
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Telephone | 601-200-2000
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Fax | 600-200-0924
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Provider Business Mailing Address
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Address Line | 969 LAKELAND DR
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City | JACKSON
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State | MS
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Zip | 39216-4606
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Country | US
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Telephone | 601-200-2000
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Fax | 600-200-0924
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT
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Name | MR. PETER G. KOURY
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Credential | CPA, FHFMA
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Telephone | 601-200-6950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 273R00000X
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Taxonomy Name | Psychiatric Hospital Unit
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License Number | 14-031
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License Number State | MS
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