Provider Demographics
NPI:1962517185
Name:JEFFERSON COMPREHENSIVE HEALTH CENTER, INC.
Entity type:Organization
Organization Name:JEFFERSON COMPREHENSIVE HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS-STAMPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-786-3475
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0098
Mailing Address - Country:US
Mailing Address - Phone:601-786-3475
Mailing Address - Fax:601-786-9980
Practice Address - Street 1:225 COMMUNITY DR
Practice Address - Street 2:POST OFFICE BOX 98
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-0098
Practice Address - Country:US
Practice Address - Phone:601-786-3475
Practice Address - Fax:601-786-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09010057Medicaid
MS09010057Medicaid