Provider Demographics
NPI:1265700637
Name:JACKSON MADISON COUNTY REGIONAL HEALTH DEPARTMENT
Entity type:Organization
Organization Name:JACKSON MADISON COUNTY REGIONAL HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PUBLIC HEALTH REPRESENATIVE
Authorized Official - Prefix:
Authorized Official - First Name:QUILL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BRABHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:731-423-3020
Mailing Address - Street 1:804 N PARKWAY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3058
Mailing Address - Country:US
Mailing Address - Phone:731-423-3020
Mailing Address - Fax:731-927-8601
Practice Address - Street 1:804 N PARKWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3058
Practice Address - Country:US
Practice Address - Phone:731-423-3020
Practice Address - Fax:731-927-8601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0157449RE261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4448133Medicaid
TN3914083Medicare Oscar/Certification
TN5607Medicare UPIN
TN4448133Medicaid