Healthcare Provider Details

I. General information

NPI: 1003203274
Provider Name (Legal Business Name): JENNIFER SUE YOUNG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER SUE SMITH APRN

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CREASON RD
CORNING AR
72422-1716
US

IV. Provider business mailing address

PO BOX 83
CORNING AR
72422-0083
US

V. Phone/Fax

Practice location:
  • Phone: 870-857-3399
  • Fax:
Mailing address:
  • Phone: 870-857-3334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberA004391
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: