Provider Demographics
NPI:1891328480
Name:JEFFERSON COMPREHENSIVE HEALTH CENTER INC
Entity Type:Organization
Organization Name:JEFFERSON COMPREHENSIVE HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS-STAMPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-786-3475
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0098
Mailing Address - Country:US
Mailing Address - Phone:601-786-3475
Mailing Address - Fax:601-786-6320
Practice Address - Street 1:405 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-5576
Practice Address - Country:US
Practice Address - Phone:601-786-3475
Practice Address - Fax:601-786-6320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)