Provider Demographics
NPI:1346305828
Name:CITY OF JACKSONVILLE
Entity Type:Organization
Organization Name:CITY OF JACKSONVILLE
Other - Org Name:CITY OF JACKSONVILLE EMS
Other - Org Type:Other Name
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:AUTHORIZED OFFICIAL
Authorized Official - Phone:903-586-7131
Mailing Address - Street 1:911 S BOLTON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2905
Mailing Address - Country:US
Mailing Address - Phone:903-586-7131
Mailing Address - Fax:803-586-4609
Practice Address - Street 1:911 S BOLTON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2905
Practice Address - Country:US
Practice Address - Phone:903-586-7131
Practice Address - Fax:903-586-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0370013416L0300X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0002198-01Medicaid