Healthcare Provider Details

I. General information

NPI: 1952838146
Provider Name (Legal Business Name): KADIJAH BERNICE RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 W MAIN ST STE 3
JACKSONVILLE AR
72076-4251
US

IV. Provider business mailing address

2227 W MAIN ST STE 3
JACKSONVILLE AR
72076-4251
US

V. Phone/Fax

Practice location:
  • Phone: 501-985-9944
  • Fax:
Mailing address:
  • Phone: 501-985-9944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number247200000X
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: