Healthcare Provider Details

I. General information

NPI: 1396609202
Provider Name (Legal Business Name): JESSE NEWTON ROY ROOT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TOWN CENTER DR STE A
HARRISON AR
72601-3038
US

IV. Provider business mailing address

PO BOX 190
KINGSTON AR
72742-0190
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-8289
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: