Healthcare Provider Details

I. General information

NPI: 1700711074
Provider Name (Legal Business Name): JENNIFER MICHELE RUDDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 IRONWOOD LN
FORT SMITH AR
72916-8842
US

IV. Provider business mailing address

6215 IRONWOOD LN
FORT SMITH AR
72916-8842
US

V. Phone/Fax

Practice location:
  • Phone: 479-719-6829
  • Fax:
Mailing address:
  • Phone: 479-719-6829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: