Provider Demographics
NPI:1184611741
Name:JEFFERSON COUNTY NURSING HOME
Entity type:Organization
Organization Name:JEFFERSON COUNTY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONTINA
Authorized Official - Middle Name:FLETCHER
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-786-3888
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-1089
Mailing Address - Country:US
Mailing Address - Phone:601-786-3888
Mailing Address - Fax:601-786-9400
Practice Address - Street 1:910 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-5524
Practice Address - Country:US
Practice Address - Phone:601-786-3888
Practice Address - Fax:601-786-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS711314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770618Medicaid
MS00220117Medicaid
MS00220117Medicaid