Provider Demographics
NPI:1528210705
Name:JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:JACKSONVILLE, LLC
Other - Org Name:JACKSONVILLE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, HCNA AND OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:J. TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-788-3342
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:800-577-5368
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:800 W STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2290
Practice Address - Country:US
Practice Address - Phone:217-243-9471
Practice Address - Fax:217-243-5359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health