Provider Demographics
NPI:1376964379
Name:HEALTHSTAT ON-SITE CLINIC/UNIFIED BRANDS JACKSON
Entity Type:Organization
Organization Name:HEALTHSTAT ON-SITE CLINIC/UNIFIED BRANDS JACKSON
Other - Org Name:JACKSON HEALTH AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RISK MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-936-5546
Mailing Address - Street 1:4651 CHARLOTTE PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:88 ARMORY RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-7431
Practice Address - Country:US
Practice Address - Phone:989-644-3331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty