Healthcare Provider Details

I. General information

NPI: 1326883364
Provider Name (Legal Business Name): JAKE GANT HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N MAIN ST
HARRISON AR
72601-2912
US

IV. Provider business mailing address

707 N MAIN ST
HARRISON AR
72601-2912
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-2774
  • Fax:
Mailing address:
  • Phone: 870-741-2774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number684
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: