Provider Demographics
NPI:1831130764
Name:JEFFERSON HOSPITAL ASSOCIATION INC
Entity Type:Organization
Organization Name:JEFFERSON HOSPITAL ASSOCIATION INC
Other - Org Name:WATSON CHAPEL FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:NARDA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:SMITHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-879-3517
Mailing Address - Street 1:4747 DUSTY LAKE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-8742
Mailing Address - Country:US
Mailing Address - Phone:870-879-3517
Mailing Address - Fax:870-879-6049
Practice Address - Street 1:4747 DUSTY LAKE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-8742
Practice Address - Country:US
Practice Address - Phone:870-879-3517
Practice Address - Fax:870-879-6049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CU0295OtherRAILROAD MEDICARE
=========017OtherTRICARE
CU0295OtherRAILROAD MEDICARE