Basic Information
| Provider Information | |||||||||
| NPI: | 1457436214 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INTERNAL MEDICINE SPECIALIST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 S MULBERRY ST | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716037016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705417220 | ||||||||
| FaxNumber: | 8705418769 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 S MULBERRY ST | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716037016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705417220 | ||||||||
| FaxNumber: | 8705418769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | BRENNA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICS | ||||||||
| AuthorizedOfficialTelephone: | 8705417220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 163167002 | 05 | AR | MEDICAID | DF8389 | 01 | AR | RAILROAD MEDICARE | OTHER | 5F637 | 01 | AR | BLUE CROSS BLUE SHEILD | OTHER |