Provider Demographics
NPI:1407951684
Name:PROFESSIONAL HEALTH SERVICES OF JACKSON
Entity Type:Organization
Organization Name:PROFESSIONAL HEALTH SERVICES OF JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:H
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-660-8467
Mailing Address - Street 1:233 OIL WELL RD STE E
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-8014
Mailing Address - Country:US
Mailing Address - Phone:731-660-8467
Mailing Address - Fax:731-660-8495
Practice Address - Street 1:233 OIL WELL RD STE E
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-8014
Practice Address - Country:US
Practice Address - Phone:731-660-8467
Practice Address - Fax:731-660-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN556710000OtherMAGELLAN BEHAVIORAL HEALT
TN3382556Medicaid
TN3926019Medicaid
TN7567489OtherAETNA
TN556710000OtherMAGELLAN BEHAVIORAL HEALT
TN3382556Medicare ID - Type UnspecifiedCIGNA GOVENMENT SERVICES