Provider Demographics
NPI:1821749946
Name:JEFFERSON HOSPITAL ASSOCIATION, INC
Entity Type:Organization
Organization Name:JEFFERSON HOSPITAL ASSOCIATION, INC
Other - Org Name:JEFFERSON REGIONAL MONTICELLO MEDICAL CLINIC 2
Other - Org Type:Other Name
Authorized Official - Title/Position:CORPORATE COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-7395
Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-2650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:733 ROBERTS DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5724
Practice Address - Country:US
Practice Address - Phone:870-460-4763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-11
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty