Healthcare Provider Details

I. General information

NPI: 1710931985
Provider Name (Legal Business Name): JEFFERSON HOSPITAL ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/21/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W. 40TH AVENUE
PINE BLUFF AR
71603-6301
US

IV. Provider business mailing address

1600 W. 40TH AVENUE
PINE BLUFF AR
71603-6301
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-7100
  • Fax: 870-541-7964
Mailing address:
  • Phone: 870-541-7100
  • Fax: 870-541-7966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License NumberAR4213
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberAR4213
License Number StateAR

VIII. Authorized Official

Name: MRS. KRISTEN JADE DAVIS
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 870-541-7173