Provider Demographics
NPI:1386018083
Name:JEFFERSON COUNTY HOSPITAL
Entity Type:Organization
Organization Name:JEFFERSON COUNTY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-786-3401
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0577
Mailing Address - Country:US
Mailing Address - Phone:601-786-3401
Mailing Address - Fax:601-786-3400
Practice Address - Street 1:870 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-5695
Practice Address - Country:US
Practice Address - Phone:601-786-3401
Practice Address - Fax:601-786-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21-238273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS25S060OtherMEDICARE PTAN