Provider Demographics
NPI:1750742318
Name:JACKSON HOSPITAL AND CLINIC INC
Entity type:Organization
Organization Name:JACKSON HOSPITAL AND CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-240-2335
Mailing Address - Street 1:1722 PINE ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1103
Mailing Address - Country:US
Mailing Address - Phone:334-240-2337
Mailing Address - Fax:334-293-6859
Practice Address - Street 1:707 MCQUEEN SMITH RD S
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7503
Practice Address - Country:US
Practice Address - Phone:334-264-9191
Practice Address - Fax:334-264-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty