Provider Demographics
NPI:1922271691
Name:JEFFERSON COMPREHENSIVE HEALTH CENTER INC
Entity Type:Organization
Organization Name:JEFFERSON COMPREHENSIVE HEALTH CENTER INC
Other - Org Name:JCHC SCHOOL BASED CLINIC HIGH SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:601-786-3475
Mailing Address - Street 1:POST OFFICE BOX 98
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-5515
Mailing Address - Country:US
Mailing Address - Phone:601-786-3475
Mailing Address - Fax:601-786-9980
Practice Address - Street 1:ROUTE 1 BOX 266
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-786-3475
Practice Address - Fax:601-786-9980
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COMPREHENSIVE HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-02
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015636Medicaid
MS09015636Medicaid