Healthcare Provider Details

I. General information

NPI: 1558679761
Provider Name (Legal Business Name): JENNETTE LEE HILES LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2161 AR 56 HWY
CALICO ROCK AR
72519-7009
US

IV. Provider business mailing address

265 COOK LANE
WIDEMAN AR
72585-0265
US

V. Phone/Fax

Practice location:
  • Phone: 870-404-4329
  • Fax:
Mailing address:
  • Phone: 870-404-4329
  • Fax: 870-297-8468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1513
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: