Provider Demographics
NPI:1558487397
Name:JACKSON MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:JACKSON MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:RYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-246-9021
Mailing Address - Street 1:220 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:AL
Mailing Address - Zip Code:36545-2459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-2459
Practice Address - Country:US
Practice Address - Phone:251-246-9021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALH1302275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4791280SMedicaid
AL4791280SMedicaid