Provider Demographics
NPI:1831206713
Name:JACKSON EMERGENCY TRANSPORT SERVICE, LLC
Entity type:Organization
Organization Name:JACKSON EMERGENCY TRANSPORT SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-P
Authorized Official - Phone:614-422-7281
Mailing Address - Street 1:PO BOX 2037
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39442-2037
Mailing Address - Country:US
Mailing Address - Phone:601-422-7281
Mailing Address - Fax:
Practice Address - Street 1:133 COURT ST
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3228
Practice Address - Country:US
Practice Address - Phone:601-422-7281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5523416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51050479OtherBCBS
AL200013112Medicaid
AL51050479OtherBCBS