Provider Demographics
NPI:1467516948
Name:JACKSON FOREST EMERGENCY AMBULANCE SERVICE
Entity type:Organization
Organization Name:JACKSON FOREST EMERGENCY AMBULANCE SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHARITY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-957-2781
Mailing Address - Street 1:PO BOX 21727
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121-0727
Mailing Address - Country:US
Mailing Address - Phone:440-605-9117
Mailing Address - Fax:440-442-4443
Practice Address - Street 1:211 W LIMA ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:OH
Practice Address - Zip Code:45843-1129
Practice Address - Country:US
Practice Address - Phone:419-273-2713
Practice Address - Fax:419-273-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0310569Medicaid
OH590006210OtherRAILROAD MEDICARE
OH590006210OtherRAILROAD MEDICARE