Provider Demographics
NPI:1376097089
Name:JACKSON HOSPITAL AND CLINIC INC.
Entity Type:Organization
Organization Name:JACKSON HOSPITAL AND CLINIC INC.
Other - Org Name:JACKSON CLINIC INFECTIOUS DISEASE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-240-2335
Mailing Address - Street 1:1722 PINE ST STE 203
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1158
Mailing Address - Country:US
Mailing Address - Phone:334-293-8736
Mailing Address - Fax:334-293-8738
Practice Address - Street 1:1722 PINE ST STE 801
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1108
Practice Address - Country:US
Practice Address - Phone:334-293-6871
Practice Address - Fax:334-293-6872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-10
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty