Healthcare Provider Details

I. General information

NPI: 1588575583
Provider Name (Legal Business Name): JILLIAN DUDLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 W COLT SQUARE DR STE 1
FAYETTEVILLE AR
72703-2888
US

IV. Provider business mailing address

719 N MALBEC RD
FAYETTEVILLE AR
72704-4012
US

V. Phone/Fax

Practice location:
  • Phone: 479-595-0333
  • Fax:
Mailing address:
  • Phone: 479-318-7041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: