Provider Demographics
NPI:1073696357
Name:JACKSON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:JACKSON COUNTY HOSPITAL DISTRICT
Other - Org Name:JACKSON MEDICAL CLINIC OF GANADO PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:VANA
Authorized Official - Last Name:HENKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-782-5241
Mailing Address - Street 1:1013 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:EDNA
Mailing Address - State:TX
Mailing Address - Zip Code:77957-4098
Mailing Address - Country:US
Mailing Address - Phone:361-782-5241
Mailing Address - Fax:361-782-7495
Practice Address - Street 1:202 S. THIRD STREET
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:TX
Practice Address - Zip Code:77962-1214
Practice Address - Country:US
Practice Address - Phone:361-771-3571
Practice Address - Fax:361-771-3574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85627001Medicaid
00U34EMedicare ID - Type Unspecified