Healthcare Provider Details

I. General information

NPI: 1639725187
Provider Name (Legal Business Name): JESSICA POLARIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 S UNIVERSITY AVE STE 10
LITTLE ROCK AR
72209-3733
US

IV. Provider business mailing address

2205 REVEILLE CIR
JACKSONVILLE AR
72076-9190
US

V. Phone/Fax

Practice location:
  • Phone: 501-251-9607
  • Fax:
Mailing address:
  • Phone: 501-218-6294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: