MEDICARE: JACKSONVILLE, LLC

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	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1437301611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 3428
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62708-3428
Country	:	US
Telephone Number	:	800-577-5368
Fax Number	:	217-757-2021

Provider Business Practice Location Address
First Line	:	1606 W LAFAYETTE AVE
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-3707
Country	:	US
Telephone Number	:	217-245-1421
Fax Number	:	217-243-1699

Authorized Official
Title or Position	:	VICE PRESIDENT, HCNA AND OPERATIONS
Name	:	J. TRAVIS DOWELL
Credential	:
Telephone Number	:	217-788-3342

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	10/09/2012

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Directions to “JACKSONVILLE, LLC ” Practice Location

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