Provider Demographics
NPI:1053571711
Name:JEFFERSON COMPREHENSIVE CARE SYSTEM INC
Entity type:Organization
Organization Name:JEFFERSON COMPREHENSIVE CARE SYSTEM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARNELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-543-2380
Mailing Address - Street 1:PO BOX 1285
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-1285
Mailing Address - Country:US
Mailing Address - Phone:870-543-2380
Mailing Address - Fax:870-535-4716
Practice Address - Street 1:1101 TENNSSEE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601
Practice Address - Country:US
Practice Address - Phone:870-543-2380
Practice Address - Fax:870-535-4716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122636741Medicaid