Jacksonville Hospital LLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

Legal business name

JACKSONVILLE HOSPITAL LLC

Practice address

1325 N Dickinson Dr
Rusk, TX 75785-1051

Phone

(903) 583-3600

Fax

(903) 583-3595

NPI assigned

Feb 10, 2018

Last updated

Oct 1, 2023By the provider in NPPES

Organization subpart

Yes

Parent organization

AHS EAST TEXAS HEALTH SYSTEM, LLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Stephen C Petrovich

Title

Evp

Phone

(615) 296-3000

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1770082299. Details of each certification follow.

• CCN 458891 Rural health clinic · Active · Details

Rural health clinic certification: CCN 458891

Legal name

JACKSONVILLE HOSPITAL LLC

Doing business as

UT HEALTH EAST TEXAS RUSK PHYSICIAN

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Sep 10, 2010

Last certification

Dec 13, 2016

Ownership / control type

1B

Most recent change of ownership

Mar 1, 2018 (1 total)

Organization structure

LLCProprietary

Incorporated

Dec 19, 2017 in DE

Enrollment address

1325 N Dickinson Dr
Rusk, TX 75785-1051

Related CCNs

450194

Related certifications (CCN) 1

Facilities connected through Provider of Services related, parent or unit certification numbers.

• Jacksonville Hospital LLC

  dba UTHealth East Texas Jacksonville Hospital

  • General Acute Care Hospital
  • Jacksonville, TX
  • NPI 1730697350

  Parent provider

  Provider of Services

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• Jacksonville Hospital LLC

  • Rural Health Clinic/Center
  • Frankston, TX
  • NPI 1043719560

  4284996638

  Same PAC ID
• Jacksonville Hospital LLC

  dba UTHealth East Texas Jacksonville Hospital

  • General Acute Care Hospital
  • Jacksonville, TX
  • NPI 1730697350

  4284996638

  Same PAC ID
• Jacksonville Hospital LLC

  • Rural Health Clinic/Center
  • Jacksonville, TX
  • NPI 1861991226

  4284996638

  Same PAC ID

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

Jacksonville Hospital LLC4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

• Jacksonville Hospital LLC

  • Rural Health Clinic/Center
  • Frankston, TX
  • NPI 1043719560
  NPD tax ID
• Jacksonville Hospital LLC

  dba UTHealth East Texas Jacksonville Hospital

  • General Acute Care Hospital
  • Jacksonville, TX
  • NPI 1730697350
  NPD tax ID
• Jacksonville Hospital LLC

  • Rural Health Clinic/Center
  • Jacksonville, TX
  • NPI 1861991226
  NPD tax ID

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Facilities with the same owner 61

Facilities that share an organizational owner with 5% or greater ownership or operational control.

• Athens Hospital, LLC

  • General Acute Care Hospital
  • Athens, TX
  • NPI 1417465824

  Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Bsa Hospital LLC

  • General Acute Care Hospital
  • Amarillo, TX
  • NPI 1407191984

  Ahp Health Partners, Inc, Ahs Management Company Inc., Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Bsa Hospital LLC

  • Rehabilitation Hospital Unit
  • Amarillo, TX
  • NPI 1730425190

  Ahp Health Partners, Inc, Ahs Management Company Inc., Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Carthage Hospital, LLC

  • Rural Health Clinic/Center
  • Carthage, TX
  • NPI 1407355860

  Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Carthage Hospital, LLC

  • General Acute Care Hospital
  • Carthage, TX
  • NPI 1538667035

  Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Carthage Hospital, LLC

  • Rural Health Clinic/Center
  • Carthage, TX
  • NPI 1639678030

  Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Encompass Health Rehabilitation Hospital of Amarillo, LLC

  dba Rehabilitation Hospital of Amarillo

  • Rehabilitation Hospital
  • Amarillo, TX
  • NPI 1487443099

  Ahp Health Partners, Inc, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Etmc Physician Group Inc.

  • Rural Health Clinic/Center
  • Chandler, TX
  • NPI 1235706581

  Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Etmc Physician Group Inc.

  • Rural Health Clinic/Center
  • Gun Barrel City, TX
  • NPI 1689241945

  Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• FMC - Lubbock LLC

  dba BSA Hospice of the Southwest

  • Community Based Hospice Care Agency
  • Amarillo, TX
  • NPI 1467447854

  Ardent Legacy Holdings LLC

  CMS ownership
• Henderson Hospital, LLC

  dba UTHealth East Texas Henderson Hospital

  • General Acute Care Hospital
  • Henderson, TX
  • NPI 1326546797

  Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership
• Henderson Hospital, LLC

  • Rural Health Clinic/Center
  • Henderson, TX
  • NPI 1952800310

  Ahp Health Partners, Inc, Ahs East Texas Health System, LLC, Ahs Management Company Inc., Ahs Texas, LLC, Ardent Health Inc, Ardent Legacy Holdings LLC

  CMS ownership

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1518220800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696118400000",
    "number": "1770082299",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "340 SEVEN SPRINGS WAY STE 100",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370275697",
            "telephone_number": "615-296-3000",
            "fax_number": "615-296-6227"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1325 N DICKINSON DR",
            "city": "RUSK",
            "state": "TX",
            "postal_code": "757851051",
            "telephone_number": "903-583-3600",
            "fax_number": "903-583-3595"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSONVILLE HOSPITAL LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "AHS EAST TEXAS HEALTH SYSTEM, LLC",
        "enumeration_date": "2018-02-10",
        "last_updated": "2023-10-01",
        "certification_date": "2023-10-01",
        "status": "A",
        "authorized_official_last_name": "PETROVICH",
        "authorized_official_first_name": "STEPHEN",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "EVP",
        "authorized_official_telephone_number": "615-296-3000"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jeanna C. Heidel, PHARMD
• Linda Henderson, FNP
• Jami Lynn Hicks, APRN, CPNP-PC
• Amir Ali Homayounkhah, PMHNP-BC
• Jackets Contractors & Associates LLC
• Jenny Pratz
• John C Peyton MD
• Alva Joy Jones, LPC
• Louis Kavetski, DDS
• Kendra Verhelle MD Community Medical Care PA (Community Medical Care)

• Rural Health Clinic/Center in Rusk, TX
• Providers in Rusk, TX by specialty
• Rural Health Clinic/Center in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.