Healthcare Provider Details

I. General information

NPI: 1528786316
Provider Name (Legal Business Name): JESSICA MARIE KOPACZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA MARIE EDWARDS

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 ROGERS AVE STE 501
FORT SMITH AR
72903-4073
US

IV. Provider business mailing address

7001 ROGERS AVE STE 501
FORT SMITH AR
72903-4073
US

V. Phone/Fax

Practice location:
  • Phone: 479-573-3101
  • Fax: 479-573-3102
Mailing address:
  • Phone: 479-573-3101
  • Fax: 479-573-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number221481
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number221481
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: