Healthcare Provider Details

I. General information

NPI: 1124343074
Provider Name (Legal Business Name): JAYNA J. MONICAL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 E CENTERTON BLVD
CENTERTON AR
72719-1225
US

IV. Provider business mailing address

1225 E CENTERTON BLVD
CENTERTON AR
72719-1225
US

V. Phone/Fax

Practice location:
  • Phone: 479-795-1301
  • Fax: 479-795-1304
Mailing address:
  • Phone: 479-795-1301
  • Fax: 479-795-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2010009034
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number222403
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: