Provider Demographics
NPI:1609879246
Name:CRESTVIEW HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:CRESTVIEW HOSPITAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIR ONBOARDING & PROV ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:330 FRANKLIN RD
Mailing Address - Street 2:STE 135A
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3282
Mailing Address - Country:US
Mailing Address - Phone:615-309-3300
Mailing Address - Fax:615-309-3338
Practice Address - Street 1:330 FRANKLIN RD
Practice Address - Street 2:STE 135A
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3282
Practice Address - Country:US
Practice Address - Phone:615-309-3300
Practice Address - Fax:615-309-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33565AMedicare ID - Type Unspecified