Healthcare Provider Details

I. General information

NPI: 1790506327
Provider Name (Legal Business Name): JEREMY EDWARD ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW BROAD ST
HOXIE AR
72433-2419
US

IV. Provider business mailing address

5625 WILDFLOWER CT
JONESBORO AR
72404-8882
US

V. Phone/Fax

Practice location:
  • Phone: 870-558-9234
  • Fax:
Mailing address:
  • Phone: 870-558-9234
  • 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:
Title or Position:
Credential:
Phone: