Provider Demographics
NPI:1467532903
Name:MISSISSIPPI STATE HOSPITAL
Entity Type:Organization
Organization Name:MISSISSIPPI STATE HOSPITAL
Other - Org Name:JAQUITH NURSING HOME - WASHINGTON INN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-351-8000
Mailing Address - Street 1:PO BOX 157A
Mailing Address - Street 2:
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-0157
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:601-351-8301
Practice Address - Street 1:3550 HIGHWAY 468 W
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-5529
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:601-351-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS939314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230123Medicaid