Healthcare Provider Details

I. General information

NPI: 1730729146
Provider Name (Legal Business Name): PHISHON BASS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E MATTHEWS AVE
JONESBORO AR
72401-4347
US

IV. Provider business mailing address

2809 FOREST HOME RD
JONESBORO AR
72401-5320
US

V. Phone/Fax

Practice location:
  • Phone: 870-910-3757
  • Fax:
Mailing address:
  • Phone: 866-972-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2304005
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: