Provider Demographics
NPI:1114134814
Name:JACKSON WOMENS CARE
Entity Type:Organization
Organization Name:JACKSON WOMENS CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-693-0531
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0790
Mailing Address - Country:US
Mailing Address - Phone:606-666-6240
Mailing Address - Fax:
Practice Address - Street 1:540 JETT DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-9622
Practice Address - Country:US
Practice Address - Phone:606-666-6240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21623207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65926974Medicaid