Basic Information
| Provider Information | |||||||||
| NPI: | 1376647545 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON CLINIC PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JACKSON CLINIC PA LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383020400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314238697 | ||||||||
| FaxNumber: | 7314225743 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 W FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220330 | ||||||||
| FaxNumber: | 7314220220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RUDD | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7314220330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 0000003266 | TN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 44D0315448 | 01 | TN | CLIA | OTHER |