Healthcare Provider Details

I. General information

NPI: 1164683082
Provider Name (Legal Business Name): JOCELYN AMANDA MOODY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HENDERSON ST BOX 7630
ARKADELPHIA AR
71999-0001
US

IV. Provider business mailing address

1100 HENDERSON ST BOX 7630
ARKADELPHIA AR
71999-0001
US

V. Phone/Fax

Practice location:
  • Phone: 870-230-5426
  • Fax: 870-230-5175
Mailing address:
  • Phone: 870-230-5426
  • Fax: 870-230-5175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 380
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: