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	2088F0040X	Urogynecology and Reconstructive Pelvic Surgery (Urology) Physician

General Provider Information

NPI Number	:	1205494416
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	:	334-293-8736
Fax Number	:	334-293-8738

Provider Business Practice Location Address
First Line	:	1722 PINE ST STE 503
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-1160
Country	:	US
Telephone Number	:	334-293-8736
Fax Number	:	334-293-8738

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	KELIN PENNEY
Credential	:
Telephone Number	:	334-240-2335

Provider Enumeration Date	:	06/03/2019
Last Update Date	:	03/09/2026

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1992296370 — JACKSON HOSPITAL AND CLINIC, INC.
Practice Location Address:

1722 PINE ST STE 503
MONTGOMERY, AL
36106-1160

Practice Phone: 334-264-8741
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