Healthcare Provider Details

I. General information

NPI: 1942870316
Provider Name (Legal Business Name): JACOB SANDEFUR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIR PARK BLVD
LITTLE ROCK AR
72204-1720
US

IV. Provider business mailing address

800 FAIR PARK BLVD
LITTLE ROCK AR
72204-1720
US

V. Phone/Fax

Practice location:
  • Phone: 501-404-8007
  • Fax: 501-904-3620
Mailing address:
  • Phone: 501-404-8007
  • Fax: 501-904-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number216212
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: