Healthcare Provider Details

I. General information

NPI: 1568001386
Provider Name (Legal Business Name): JEFFERSON REGIONAL CANCER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2019
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE STE 205
PINE BLUFF AR
71603-6367
US

IV. Provider business mailing address

1012 PRINCETON ST STE 100
VERMILLION SD
57069-7202
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-1188
  • Fax: 870-541-4297
Mailing address:
  • Phone: 605-677-3312
  • Fax: 605-677-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRYAN JACKSON
Title or Position: CFO
Credential:
Phone: 605-677-3312