MEDICARE: JEFFERSON HOSPITAL ASSOCIATION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1922578327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFERSON HOSPITAL ASSOCIATION, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2650
Second Line	:
City	:	PINE BLUFF
State	:	AR
Zip	:	71613-2650
Country	:	US
Telephone Number	:	870-541-7235
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 W 40TH AVE STE 6A
Second Line	:
City	:	PINE BLUFF
State	:	AR
Zip	:	71603-6963
Country	:	US
Telephone Number	:	870-541-9373
Fax Number	:	870-541-0109

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. BRYAN JACKSON
Credential	:	CFO
Telephone Number	:	870-541-7141

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	11/28/2018

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