Basic Information
| Provider Information | |||||||||
| NPI: | 1952306672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOTHER FRANCES HOSPITAL JACKSONVILLE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHRISTUS MOTHER FRANCES HOSPITAL - JACKSONVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847522 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035414500 | ||||||||
| FaxNumber: | 9035414679 | ||||||||
| Practice Location | |||||||||
| Address1: | 2026 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757665822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035414500 | ||||||||
| FaxNumber: | 9035414679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUFF | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9036066425 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 282NC0060X | 007254 | TX | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 141858401 | 05 | TX | MEDICAID | 165773601 | 05 | TX | MEDICAID | 199777701 | 05 | TX | MEDICAID | 141858403 | 05 | TX | MEDICAID | 165773602 | 05 | TX | MEDICAID | HH0993 | 01 | TX | BLUE CROSS | OTHER |