Basic Information
| Provider Information | |||||||||
| NPI: | 1841235868 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON HOSPITAL ASSOCIATION, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JEFFERSON REGIONAL HEALTHWORKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 DUSTY LAKE DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716039057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705366600 | ||||||||
| FaxNumber: | 8705418623 | ||||||||
| Practice Location | |||||||||
| Address1: | 4747 DUSTY LAKE DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716039057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705366600 | ||||||||
| FaxNumber: | 8705341519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP/CHIEF ADMIN OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8705417141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | AR | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 56802 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER | CI2242 | 01 | AR | RAILROAD MEDICARE | OTHER |