Healthcare Provider Details

I. General information

NPI: 1619703733
Provider Name (Legal Business Name): JACQULINE LEE GATES LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 ROGERS AVE # 72901
FORT SMITH AR
72901-3933
US

IV. Provider business mailing address

2021 ROGERS AVE # 72901
FORT SMITH AR
72901-3933
US

V. Phone/Fax

Practice location:
  • Phone: 479-926-2768
  • Fax:
Mailing address:
  • Phone: 479-926-2768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8582
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: