Basic Information
| Provider Information | |||||||||
| NPI: | 1124061882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JACKSON HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1013 SOUTH WELLS STREET | ||||||||
| Address2: | |||||||||
| City: | EDNA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779574098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617825241 | ||||||||
| FaxNumber: | 3617825241 | ||||||||
| Practice Location | |||||||||
| Address1: | 1013 SOUTH WELLS STREET | ||||||||
| Address2: | |||||||||
| City: | EDNA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779574098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617825241 | ||||||||
| FaxNumber: | 3617825241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 10/27/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | ASA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3617825241 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 000017 | TX | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 121808305 | 05 | TX | MEDICAID |