NPIMap

Organization Active NPI

Jefferson Hospital Association, Inc

  • Rural Health Clinic/Center
  • Crossett, AR
National Provider Identifier
1225799646
Registry record updated Apr 1, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
JEFFERSON HOSPITAL ASSOCIATION, INC
Practice address
201 Fairview Road
Suite a
Crossett, AR 71635-4537
Phone
(870) 364-0000
NPI assigned
Jan 7, 2022
Last updated
Apr 1, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 1, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shayla Robinson
Title
Corporate Compliance Officer
Phone
(870) 541-7395

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

201 Fairview Road
Suite a
Crossett, AR 71635-4537

Mailing address

PO Box 2650
Pine Bluff, AR 71613-2650
Phone (870) 541-7211

Other names 1

  • Jefferson Regional Crossett Clinic Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040106000512 AR Part B Supplier - Clinic/Group Practice 8123927431 Receives reassigned benefits from 105 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Pine Bluff, AR; Sheridan, AR; Star City, AR; Stuttgart, AR; Warren, AR; White Hall, AR; Crossett, AR; De Witt, AR…
O20220413000684 AR Part A Provider - Rural Health Clinic 8123927431 Practice locations: Crossett, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1225799646. Details of each certification follow.

Rural health clinic certification: CCN 048532

Legal name
JEFFERSON HOSPITAL ASSOCIATION, INC
Doing business as
JEFFERSON REGIONAL CROSSETT CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 1, 2022
Last certification
Nov 2, 2022
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Sep 30, 1966 in AR
Enrollment address
201 Fairview Rd
Ste a
Crossett, AR 71635-4537
Related CCNs
040071

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D2156669Jefferson Regional- Crossett Clinic201 Fairview, Suite a, Crossett, AR 71635AccreditationJul 25, 2028

National Provider Directory

National Provider Directory
Tax ID family
Jefferson Regional Med15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

Organizations that report the same tax identification number in the National Provider Directory.

View all 14

Locations

733 Roberts Dr
#2
Monticello, AR 71655
Phone 87046047634763

1420 W 43rd Ave
Ste A
Pine Bluff, AR 71603
Phone (870) 541-6015

1600 W 40th Ave
#P
Pine Bluff, AR 71603
Phone (870) 541-7271

1600 W 40th Ave
#R
Pine Bluff, AR 71603
Phone (870) 541-7271

1601 W 40th Ave
Ste 301B
Pine Bluff, AR 71603
Phone (870) 541-7406

1601 W 40th Ave
Ste 401
Pine Bluff, AR 71603
Phone (870) 541-7201

1609 W 40th Ave
#202S
Pine Bluff, AR 71603
Phone (870) 541-0668

1609 W 40th Ave
Bldg 1
Pine Bluff, AR 71603
Phone (622) 822-9331

1609 W 40th Ave
Ste 205
Pine Bluff, AR 71603
Phone (870) 534-1188

1609 W 40th Ave
Ste 401
Pine Bluff, AR 71603
Phone (870) 535-2200

1716 Doctors Dr
#B
Pine Bluff, AR 71603
Phone (870) 535-3333

1801 W 40th Ave
Ste 4B
Pine Bluff, AR 71603
Phone (870) 535-4640

4747 Dusty Lake Dr
#I530
Pine Bluff, AR 71603
Phone (870) 850-7173

4747 Dusty Lake Dr
Ste 202
Pine Bluff, AR 71603
Phone (870) 541-7235

4747 Dusty Lake Dr
Ste G2
Pine Bluff, AR 71603
Phone (870) 534-2348

6810 S Hazel St
Pine Bluff, AR 71603
Phone (870) 541-0342

6811 S Hazel St
Pine Bluff, AR 71603
Phone (870) 535-1155

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Peter Austin Individual Corporate OfficerChief Operating Officer Feb 1, 2022
W-2 Managing EmployeeChief Operating Officer Feb 1, 2022
Jefferson Hospital Association, Inc Organization, Pine Bluff, AR Corporation, Non-profit 5% Or Greater Direct Ownership Interest Sep 30, 1966 100%
Brian Noel Thomas Individual Corporate OfficerCeo Feb 1, 2022

Owners & managing parties with NPI records 8

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Jefferson Regional Specialty HospitalWhite Hall, AR, CCN 043038 Hospital 5% Or Greater Direct Ownership Interest (60%) Jun 4, 2024
Jefferson Regional Specialty HospitalWhite Hall, AR, CCN 04SD38 Hospital 5% Or Greater Direct Ownership Interest (60%) Jun 4, 2024
Jefferson HomecareWhite Hall, AR, CCN 047093 Home health agency 5% Or Greater Direct Ownership Interest (33%) Jun 1, 2008
Jefferson Regional Monticello Medical ClinicMonticello, AR, CCN 048533 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Sep 30, 1966

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Change-of-ownership history 1

DateEventCounterparty
Feb 1, 2022 Change of OwnershipThis provider was the buyer MMC Star City ClinicCCN 043906, AR, NPI 1316443807

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Practitioners & affiliated clinicians

Practitioners 117

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 117

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1641513600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1648771200000",
    "number": "1225799646",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2650",
            "city": "PINE BLUFF",
            "state": "AR",
            "postal_code": "716132650",
            "telephone_number": "870-541-7211"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 FAIRVIEW ROAD",
            "address_2": "SUITE A",
            "city": "CROSSETT",
            "state": "AR",
            "postal_code": "716354537",
            "telephone_number": "870-364-0000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON HOSPITAL ASSOCIATION, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-01-07",
        "last_updated": "2022-04-01",
        "certification_date": "2022-04-01",
        "status": "A",
        "authorized_official_last_name": "ROBINSON",
        "authorized_official_first_name": "SHAYLA",
        "authorized_official_title_or_position": "CORPORATE COMPLIANCE OFFICER",
        "authorized_official_telephone_number": "870-541-7395"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jefferson Regional Crossett Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Crossett, AR

Sources for this page

Verify at the official NPI Registry.