Healthcare Provider Details

I. General information

NPI: 1174542906
Provider Name (Legal Business Name): JEFFERSON HOSPITAL ASSOCIATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 W 40TH SUITE 301
PINE BLUFF AR
71603
US

IV. Provider business mailing address

1601 W 40TH SUITE 301
PINE BLUFF AR
71603
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-7220
  • Fax:
Mailing address:
  • Phone: 870-541-4285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberE-4501
License Number StateAR

VIII. Authorized Official

Name: MR. WALTER JOHNSON
Title or Position: CEO
Credential:
Phone: 870-541-7269