Provider Demographics
NPI:1699832097
Name:JACKSON TRANSIT AUTHORITY
Entity Type:Organization
Organization Name:JACKSON TRANSIT AUTHORITY
Other - Org Name:JTA
Other - Org Type:Other Name
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GULLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-423-0200
Mailing Address - Street 1:241 E DEADRICK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5361
Mailing Address - Country:US
Mailing Address - Phone:731-423-0200
Mailing Address - Fax:731-424-9323
Practice Address - Street 1:241 E DEADRICK ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-5361
Practice Address - Country:US
Practice Address - Phone:731-423-0200
Practice Address - Fax:731-424-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT000171Medicaid