Provider Demographics
NPI:1790777696
Name:JACK COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:JACK COUNTY HOSPITAL DISTRICT
Other - Org Name:FAITH COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-567-6633
Mailing Address - Street 1:215 CHISHOLM TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76458-1403
Mailing Address - Country:US
Mailing Address - Phone:940-567-6633
Mailing Address - Fax:940-567-2895
Practice Address - Street 1:215 CHISHOLM TRL
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TX
Practice Address - Zip Code:76458
Practice Address - Country:US
Practice Address - Phone:940-567-6633
Practice Address - Fax:940-567-2895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X, 367500000X
TX000046282N00000X
TX100322282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119874903Medicaid
TX119874904Medicaid
TX119874905Medicaid
TX119874902Medicaid
TXHH0054OtherBC/BS PROVIDER NUMBER