Provider Demographics
NPI:1295037372
Name:JEFFERSON COMPREHENSIVE HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:JEFFERSON COMPREHENSIVE HEALTH CENTER, INC.
Other - Org Name:SCHOOL-BASED CLINIC ADAMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS-STAMPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:601-786-3475
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0098
Mailing Address - Country:US
Mailing Address - Phone:601-786-3475
Mailing Address - Fax:601-786-9980
Practice Address - Street 1:1221 N. DR. MLK JR. STREET
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-3157
Practice Address - Country:US
Practice Address - Phone:601-786-3475
Practice Address - Fax:601-786-9980
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COMPREHENSIVE HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-23
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)