Provider Demographics
NPI:1770668519
Name:JAQUITH NURSING HOME - JEFFERSON INN
Entity Type:Organization
Organization Name:JAQUITH NURSING HOME - JEFFERSON INN
Other - Org Name:JAQUITH NURSING HOME - JEFFERSON INN
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-351-8000
Mailing Address - Street 1:P.O. BOX 1 FISCAL SERVICES
Mailing Address - Street 2:3550 HWY 468 WEST
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-0157
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:601-351-8586
Practice Address - Street 1:3550 HWY 468 WEST
Practice Address - Street 2:
Practice Address - City:WHITFIELD
Practice Address - State:MS
Practice Address - Zip Code:39193-0157
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:601-351-8586
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI STATE HOSPITAL AT WHITFIELD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS941313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230125Medicaid