Basic Information
| Provider Information | |||||||||
| NPI: | 1588692370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON COUNTY HOSPITAL DISTRICT | ||||||||
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| OtherOrganizationName: | JACKSON MEDICAL CLINIC OF GANADO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1013 S WELLS ST | ||||||||
| Address2: | |||||||||
| City: | EDNA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779574098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617825241 | ||||||||
| FaxNumber: | 3617827495 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 S THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | GANADO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779621214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617713571 | ||||||||
| FaxNumber: | 3617713574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HENKE | ||||||||
| AuthorizedOfficialFirstName: | MARCELLA | ||||||||
| AuthorizedOfficialMiddleName: | VANA | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3617825241 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 85637001 | 05 | TX | MEDICAID |