Provider Demographics
NPI:1437258043
Name:PRIMARY CARE PROVIDERS FOR A HEALTHY FELICIANA, INC.
Entity Type:Organization
Organization Name:PRIMARY CARE PROVIDERS FOR A HEALTHY FELICIANA, INC.
Other - Org Name:JACKSON COMPLEX HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTI
Authorized Official - Middle Name:C
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-683-5292
Mailing Address - Street 1:P.O. BOX 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-5292
Mailing Address - Fax:225-683-1310
Practice Address - Street 1:3619 HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748
Practice Address - Country:US
Practice Address - Phone:225-683-1360
Practice Address - Fax:225-634-0005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMARY CARE PROVIDERS FOR A HEALTHY FELICIANA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1448389Medicaid
LA1448389Medicaid