Healthcare Provider Details

I. General information

NPI: 1669851929
Provider Name (Legal Business Name): JEFFERSON HOSPITAL ASSOCIATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 40TH AVE
PINE BLUFF AR
71603-6301
US

IV. Provider business mailing address

1600 W 40TH AVE
PINE BLUFF AR
71603-6301
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-7100
  • Fax:
Mailing address:
  • Phone: 870-541-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN THOMAS
Title or Position: CEO
Credential:
Phone: 870-541-7100