Provider Demographics
NPI:1659879633
Name:JACKSON HOSPITAL AND CLINIC, INC
Entity Type:Organization
Organization Name:JACKSON HOSPITAL AND CLINIC, INC
Other - Org Name:JACKSON CLINIC GASTROENTEROLOGY PRATTVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-240-2335
Mailing Address - Street 1:1722 PINE ST STE 503
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1160
Mailing Address - Country:US
Mailing Address - Phone:334-293-8736
Mailing Address - Fax:334-293-8738
Practice Address - Street 1:707 MCQUEEN SMITH RD S
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7503
Practice Address - Country:US
Practice Address - Phone:334-293-6825
Practice Address - Fax:334-293-6826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty