Provider Demographics
NPI:1144520677
Name:JEFFERSON COMMUNITY HEALTH CARE CENTERS
Entity type:Organization
Organization Name:JEFFERSON COMMUNITY HEALTH CARE CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-328-0488
Mailing Address - Street 1:1855 AMES BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3429
Mailing Address - Country:US
Mailing Address - Phone:504-328-0488
Mailing Address - Fax:504-328-0899
Practice Address - Street 1:1855 AMES BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3429
Practice Address - Country:US
Practice Address - Phone:504-328-0488
Practice Address - Fax:504-328-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1015199Medicaid
LA528Medicare UPIN