Provider Demographics
NPI:1770593204
Name:CITY OF JACKSON HEALTHCARE AUTHORITY
Entity type:Organization
Organization Name:CITY OF JACKSON HEALTHCARE AUTHORITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:RYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-246-9021
Mailing Address - Street 1:112 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:AL
Mailing Address - Zip Code:36545
Mailing Address - Country:US
Mailing Address - Phone:251-247-0424
Mailing Address - Fax:251-247-0428
Practice Address - Street 1:3748 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-2225
Practice Address - Country:US
Practice Address - Phone:251-247-0424
Practice Address - Fax:251-247-0428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11779251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALJAC7112AMedicaid
AL510-99896OtherBLUE CROSS BLUE SHIELD
ALJAC7112AMedicaid