Provider Demographics
NPI:1306047105
Name:MERCY CLINIC OF JACKSON, PLLC
Entity type:Organization
Organization Name:MERCY CLINIC OF JACKSON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-693-0343
Mailing Address - Street 1:1550 HIGHWAY 15 S
Mailing Address - Street 2:SUITE 80
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-7247
Mailing Address - Country:US
Mailing Address - Phone:606-693-0343
Mailing Address - Fax:606-693-0322
Practice Address - Street 1:1550 HIGHWAY 15 S
Practice Address - Street 2:SUITE 80
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-7247
Practice Address - Country:US
Practice Address - Phone:606-693-0343
Practice Address - Fax:606-693-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31497174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9700Medicare ID - Type Unspecified