Provider Demographics
NPI:1972533990
Name:JEFFERSON COUNTY COMPREHENSIVE
Entity Type:Organization
Organization Name:JEFFERSON COUNTY COMPREHENSIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEHMER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:618-242-1510
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-242-1510
Mailing Address - Fax:618-242-0958
Practice Address - Street 1:16342 N IL HWY 37
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-242-1510
Practice Address - Fax:618-242-0958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
372631OtherHEALTHLINK
IL0004115177OtherBCBS
497770000OtherMAGELLAN
372631OtherHEALTHLINK
372631OtherHEALTHLINK
IL970060Medicare PIN