Provider Demographics
NPI:1043262488
Name:JACKSON HOSPITAL & CLINIC, INC.
Entity Type:Organization
Organization Name:JACKSON HOSPITAL & CLINIC, INC.
Other - Org Name:JACKSON HOSPITAL & CLINIC, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-293-8820
Mailing Address - Street 1:1725 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1103
Mailing Address - Country:US
Mailing Address - Phone:334-293-8000
Mailing Address - Fax:334-293-8161
Practice Address - Street 1:1725 PINE ST
Practice Address - Street 2:DEPARTMENT OF PHARMACY
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1109
Practice Address - Country:US
Practice Address - Phone:334-293-8780
Practice Address - Fax:334-293-8791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA88282N00000X
AL140004333600000X
AL2162053333600000X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162053OtherPK
AL010024Medicare Oscar/Certification