Healthcare Provider Details

I. General information

NPI: 1821021379
Provider Name (Legal Business Name): JEFFERSON HOSPITAL ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE SUITE 207
PINE BLUFF AR
71603-6319
US

IV. Provider business mailing address

1609 W 40TH AVE SUITE 207
PINE BLUFF AR
71603-6319
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-2348
  • Fax: 870-850-6816
Mailing address:
  • Phone: 870-534-2348
  • Fax: 870-850-6816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberE2787
License Number StateAR

VIII. Authorized Official

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