Provider Demographics
NPI:1710931985
Name:JEFFERSON HOSPITAL ASSOCIATION INC
Entity Type:Organization
Organization Name:JEFFERSON HOSPITAL ASSOCIATION INC
Other - Org Name:JEFFERSON REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:JADE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-7173
Mailing Address - Street 1:1600 W. 40TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6301
Mailing Address - Country:US
Mailing Address - Phone:870-541-7100
Mailing Address - Fax:870-541-7966
Practice Address - Street 1:1600 W. 40TH AVENUE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6301
Practice Address - Country:US
Practice Address - Phone:870-541-7100
Practice Address - Fax:870-541-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
273R00000X, 273Y00000X, 282N00000X, 314000000X
ARAR4213273Y00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
No273Y00000XHospital UnitsRehabilitation Unit
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR040071OtherMEDICARE PART A
AR103078002Medicaid
AR5000023OtherUNITED HEALTHCARE
AR045307OtherMEDICARE PART A
AR04S071OtherMEDICARE PART A
AR10071OtherBLUE CROSS PROVIDER #
AR102916105Medicaid
AR15307OtherBLUE CROSS SNF PROVIDER #
AR102916105Medicaid
AR15307OtherBLUE CROSS SNF PROVIDER #
AR103078002Medicaid
AR04T071Medicare Oscar/Certification