Basic Information
| Provider Information | |||||||||
| NPI: | 1134417975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JACKSON GENERAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720 | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252710720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043722731 | ||||||||
| FaxNumber: | 3043733749 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ACADEMY DRIVE | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252719101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043722731 | ||||||||
| FaxNumber: | 3043722749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3043731475 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 52 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1134417976 | 01 | WV | NPI | OTHER | 3810021320 | 05 | WV | MEDICAID |