MEDICARE: JACKSON HOSPITAL AND CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician

General Provider Information

NPI Number	:	1164803367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON HOSPITAL AND CLINIC INC

Provider Business Mailing Address
First Line	:	1722 PINE ST STE 804
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-1108
Country	:	US
Telephone Number	:	334-240-2337
Fax Number	:	334-293-6859

Provider Business Practice Location Address
First Line	:	226 MITYLENE PARK DR
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-3548
Country	:	US
Telephone Number	:	334-281-7666
Fax Number	:	334-293-6859

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KELIN PENNEY
Credential	:
Telephone Number	:	334-240-2337

Provider Enumeration Date	:	06/12/2015
Last Update Date	:	03/09/2026

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