Provider Demographics
NPI:1306097365
Name:JEFFERSON HOSPITAL ASSOCIATION, INC.
Entity type:Organization
Organization Name:JEFFERSON HOSPITAL ASSOCIATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-7269
Mailing Address - Street 1:7500 DOLLARWAY RD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-3027
Mailing Address - Country:US
Mailing Address - Phone:870-879-9595
Mailing Address - Fax:870-879-9599
Practice Address - Street 1:7500 DOLLARWAY RD
Practice Address - Street 2:SUITE 404
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-3027
Practice Address - Country:US
Practice Address - Phone:870-879-9595
Practice Address - Fax:870-879-9599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176263002Medicaid
AR5G130OtherBLUE CROSS BLUE SHIELD
AR176263002Medicaid