Provider Demographics
NPI:1851068324
Name:JACKSON FREE CLINIC
Entity Type:Organization
Organization Name:JACKSON FREE CLINIC
Other - Org Name:JACKSON FREE CLINIC FOR THE HOMELESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHAIR OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:HALI
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-355-5161
Mailing Address - Street 1:PO BOX 4892
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4892
Mailing Address - Country:US
Mailing Address - Phone:601-355-5161
Mailing Address - Fax:
Practice Address - Street 1:925 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39203-2233
Practice Address - Country:US
Practice Address - Phone:601-355-5161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable