Provider Demographics
NPI:1992892301
Name:HOSPICE OF JACKSON
Entity type:Organization
Organization Name:HOSPICE OF JACKSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP - CMO, CEO - HFAMG
Authorized Official - Prefix:MS
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-205-6407
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:ONE JACKSON SQUARE, SUITE 400
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-841-6982
Mailing Address - Fax:517-841-6987
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:ONE JACKSON SQUARE, SUITE 400
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-841-6982
Practice Address - Fax:517-841-6987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI383510251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI70031199OtherACS
MI08712OtherBLUE CROSS OF MICHIGAN
MIHS380001OtherMCARE
MI0078OtherHEALTH PLAN OF MICHIGAN
MI50-20015OtherPHYSICIAN'S HEALTH PLAN
MI1825474-16Medicaid
MI500458OtherCARE CHOICE
MI08712OtherBLUE CROSS OF MICHIGAN