Provider Demographics
NPI:1407859127
Name:JERNIGAN HEALTHCARE, INC.
Entity Type:Organization
Organization Name:JERNIGAN HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-631-1520
Mailing Address - Street 1:PO BOX 879
Mailing Address - Street 2:
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-0879
Mailing Address - Country:US
Mailing Address - Phone:205-631-1520
Mailing Address - Fax:205-631-1522
Practice Address - Street 1:901 DECATUR HWY
Practice Address - Street 2:
Practice Address - City:FULTONDALE
Practice Address - State:AL
Practice Address - Zip Code:35068-1815
Practice Address - Country:US
Practice Address - Phone:205-631-1520
Practice Address - Fax:205-631-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL182332B00000X
AL23573332BX2000X
AL23756333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009508430Medicaid
AL510-50377OtherBLUE CROSS SUPPLIER
MS00440281Medicaid
AL510-50377OtherBLUE CROSS SUPPLIER