MEDICARE: JACOB MICHAEL PONDER APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	A004482	AR

General Provider Information

NPI Number	:	1225413693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MICHAEL PONDER APRN

Provider Business Mailing Address
First Line	:	8301 LEAWOOD BLVD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-1616
Country	:	US
Telephone Number	:	310-923-5754
Fax Number	:

Provider Business Practice Location Address
First Line	:	5326 WEST MARKHAM STREET
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205
Country	:	US
Telephone Number	:	501-603-9885
Fax Number	:	501-603-9898

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2015
Last Update Date	:	07/20/2016

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