Provider Demographics
NPI:1568001386
Name:JEFFERSON REGIONAL CANCER CENTER
Entity type:Organization
Organization Name:JEFFERSON REGIONAL CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-677-3312
Mailing Address - Street 1:1012 PRINCETON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-7202
Mailing Address - Country:US
Mailing Address - Phone:605-677-3312
Mailing Address - Fax:605-677-3301
Practice Address - Street 1:1609 W 40TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6367
Practice Address - Country:US
Practice Address - Phone:870-534-1188
Practice Address - Fax:870-541-4297
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON HOSPITAL ASSOCIATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology