Healthcare Provider Details

I. General information

NPI: 1982562427
Provider Name (Legal Business Name): UNITED STATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

0 POPE ST
GOULD AR
71643
US

IV. Provider business mailing address

0 POPE ST
GOULD AR
71643
US

V. Phone/Fax

Practice location:
  • Phone: 501-593-9715
  • Fax:
Mailing address:
  • Phone: 501-593-9715
  • 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: JENNIFER TAWANDA BROWN GAINES
Title or Position: G/I DEPUTY POLICE OFFICER AT LAW
Credential: DR
Phone: 870-540-9476