Healthcare Provider Details

I. General information

NPI: 1154386597
Provider Name (Legal Business Name): JEFFERSON COMPREHENSIVE CARE SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 TENNESSEE ST
PINE BLUFF AR
71601-5801
US

IV. Provider business mailing address

PO BOX 1285
PINE BLUFF AR
71613-1285
US

V. Phone/Fax

Practice location:
  • Phone: 870-543-2380
  • Fax: 870-535-4716
Mailing address:
  • Phone: 870-543-2380
  • Fax: 870-535-4716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. LARNELL W DAVIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 870-543-2380