Healthcare Provider Details

I. General information

NPI: 1699438051
Provider Name (Legal Business Name): JASON EDWARDS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 W PARKER RD
JONESBORO AR
72404-7486
US

IV. Provider business mailing address

2217 W PARKER RD
JONESBORO AR
72404-7486
US

V. Phone/Fax

Practice location:
  • Phone: 870-207-6215
  • Fax: 870-207-6305
Mailing address:
  • Phone: 870-207-6215
  • Fax: 870-207-6305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number3233
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: