Provider Demographics
NPI:1043204555
Name:JEFFERSON COUNTY HOSPITAL
Entity Type:Organization
Organization Name:JEFFERSON COUNTY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERM CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-597-4979
Mailing Address - Street 1:P.O. BOX 577
Mailing Address - Street 2:870 MAIN STREET
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0577
Mailing Address - Country:US
Mailing Address - Phone:601-786-3401
Mailing Address - Fax:601-786-3400
Practice Address - Street 1:870 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-0577
Practice Address - Country:US
Practice Address - Phone:601-786-3401
Practice Address - Fax:601-786-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21238273R00000X, 282N00000X
282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No273R00000XHospital UnitsPsychiatric Unit
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02109OtherBLUE CROSS BLUE SHIELD
MS250060Medicare PIN
MS25U060Medicare PIN
MS25S060Medicare PIN