Basic Information
Provider Information | |||||||||
NPI: | 1417293846 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JACKSON HOSPITAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CAMPTON RURAL HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 689022 | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | TN | ||||||||
PostalCode: | 370689022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8007097338 | ||||||||
FaxNumber: | 6154696505 | ||||||||
Practice Location | |||||||||
Address1: | 49 KY 15 N | ||||||||
Address2: |   | ||||||||
City: | CAMPTON | ||||||||
State: | KY | ||||||||
PostalCode: | 413017284 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066689841 | ||||||||
FaxNumber: | 6066687730 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2012 | ||||||||
LastUpdateDate: | 05/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICHARDSON | ||||||||
AuthorizedOfficialFirstName: | TARA | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | VP PATIENT FINANCIAL SERVICES | ||||||||
AuthorizedOfficialTelephone: | 6152213672 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | JACKSON HOSPITAL CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 100620 | KY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.